Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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

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

  

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

 

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

Writing a Birth Plan by findadoula.com

 

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

 

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

 

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

Writing a Birth Plan by findadoula.com

 

 

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

How to write a Birth Plan by birthingnaturally.net

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

The Six Lamaze Healthy Birth Practices are:

 1. Let labor begin on its own.

 

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

 

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

 

4. Avoid interventions that are not medically necessary.

 

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

 

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

 

The topics of the print materials include: 

Choosing a Care Provider,

Changing Your Care Provider,

If You Have Been Induced,

Maintaining Freedom of Movement,

Positions for Labor,

Finding a Doula,

Creating a Support Team,

Tips for Labor Support People

and even a Birth Planning Worksheet!!

 

 

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

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

by Amy Scott

 

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

 

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

 

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

 

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

 

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

 

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

Creating Your Birth Plan, page 219

By Marsden Wagner & Stephanie Gunning

 

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

 

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

 

Let me give you a few examples:

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

a)      BirthingNaturally.net

b)      Sample Birth Plans from BirthingNaturally.net

c)      ChoicesinChildbirth.com

d)      American Pregnancy Association

e)      BabyCenter.com

f)      MothersAdvocate.com

 

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

 

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

 

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

Creating Your Birth Plan, page 219

By Marsden Wagner & Stephanie Gunning

 

 

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

 

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

 

And finally…

 

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

 

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

 

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

SAMPLE BIRTH PLAN

 

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

 

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

Birth Preferences:

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

Your help with these preferences is very much appreciated.

 

Labor:

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

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

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

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

 

Birth:

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

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

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

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

 

If Cesarean Is Required:

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

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

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

 

Baby Care:

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

 

We Appreciate Your Support. Thank You!

Advertisements
 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

My goals for this post are the following:

 

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

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

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

 

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

 

 

What Exactly is a Birth Plan?

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

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

 

 

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

 

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

 

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

2. Script the nature of your labor.

3. Insure you have a satisfying labor. 

 

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

 

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

(Birthing From Within, pages 96-97)

 

 

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

 

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

 

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

 

In her article Lela Davidson writes:

 

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

 

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

 

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

 

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

 

Consent for Anesthesia: Do You Know What You Are Signing? May 5, 2009

As an L&D nurse, one of the first questions we ask of our patients during their admission interview is if they have a birth plan and what their plans are for pain management during labor.  Here are the 5 most common responses to that question:

#1   I would like to have a natural/unmedicated childbirth, Please do not offer me any medications/epidural because I will ask for them if I decided I need them.

#2   I am pretty sure I want to have a natural/unmedicated childbirth, but I haven’t ruled out the possibility of any medications/epidural because I don’t know what to expect.  However, I’d like to go as long as possible without them.

#3   I definitely want pain medication but I do not want an epidural because:

a.  I don’t like the idea of a needle in my back,

b.  My best friend/sister had a horrible experience with it.

#4   I want an epidural as soon as I can have one but I want to try to avoid pain medication because:

a. I heard it can make you feel out of it/loopy,

b. My best friend/sister had a horrible experience with it.

#5   I want everything and anything you can give me as soon as you can give it to me…I don’t want to miss my “window” for an epidural either!   Can’t I just have the epidural now?

 

What I have always found interesting is that except for some women who answer #1, I rarely hear reasons for not wanting either pain medication or an epidural that include the very real risks of:

“Because it can negatively affect my baby.”

“Because it can negatively affect me.”

“Because it can negatively affect my labor progress.”

“Because it can negatively affect my chances for a vaginal delivery.”

 

After hearing the mothers’ responses and if time allows, I typically ask them how they prepared for labor and childbirth and how they came to their plan of wanting or wanting to avoid pain medications or an epidural.  Not surprisingly, the most common responses for women who answered #2 through #5 are: “I only took the hospital tour/childbirth class,” “I only read ‘What to Expect When You’re Expecting’”, “I only talked to my other friends/family who have had a baby,” or “I didn’t do anything really.”

 

I am going to be quite honest here.  It pretty much baffles me that women who are planning on utilizing pain medication and/or an epidural during labor typically have not learned much more about them besides when they can be given and how they are given.  That is, in my experience as an L&D nurse, the RISKS of the procedure are rarely if ever fully understood and the BENEFITS are often exaggerated.  Whenever I get the chance, if I feel that a woman has not researched the risks and benefits of pain medication/epidural during her pregnancy, I will try to go over them fairly and accurately if time and circumstances allow.  I typically only get this chance if they are being admitted for an induction.  On the contrary, if they come in during active labor and are very uncomfortable, I try to do my best to explain risks and benefits but I also struggle with trying to be sensitive to the fact that they are uncomfortable and probably aren’t or can’t completely pay attention to everything I am going over.  It’s really quite the predicament.

I guess what I am trying to get at is that women need to start taking control of their own bodies and health care decisions.  The fact of the matter is, “TRULY INFORMED CONSENT IS ONLY POSSIBLE BY CONSUMER INITIATIVE.  PERSONAL EDUCATION IS A PERSONAL RESPONSIBILITY.”  ~ David Stewart, founder and director of NAPSAC***

What does that mean you ask?  To me, this quote means that true informed consent is only accomplished and insured when the health care professional (e.g. obstetrician, anesthesiologist and sometimes even the midwife or nurse) AND the consumer (i.e. the pregnant woman/childbearing family) are BOTH active participants in the informed consent process.

Regarding the role of the health care professional, the American Medical Association defines informed consent in the following way:

Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. In the communications process the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with [the] patient:

 

(1) The patient’s diagnosis, if known;

(2) The nature and purpose of a proposed treatment or procedure;

(3) The risks and benefits of a proposed treatment or procedure;

(4) Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);

(5) The risks and benefits of the alternative treatment or procedure; and

(6) The risks and benefits of not receiving or undergoing a treatment or procedure.

 

In turn, [the] patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

 

 

Now that you are informed about the role of your health care provider, I would like to remind all consumers of health care that might be reading this blog (i.e. pregnant women/childbearing families) that if you forfeit or ignore your personal responsibility to educating and preparing yourself for pregnancy, labor, childbirth, and postpartum, then IT IS YOU THAT HAS TO LIVE WITH THE DECISIONS YOU LET YOUR HEALTH CARE PROVIDER MAKE FOR YOU!  David Stewart writes,

“Professionals do not always have the best answers.  This is not a criticism of professionals, but a simple recognition of the fact.  It serves neither professionals nor patients to disregard this fact.  All have limited experience and limited education.  The best health care is available to consumers who participate in medical decisions pertaining to themselves and their families.  …To be fully informed requires preparation and education before [the fact].  Doctors and medical institutions have a clear obligation to assist patients by providing unbiased pros and cons of policies and procedures.  They do not have the obligation to be a patient’s sole and complete source of education.”***

 

 

I know I would be better able to sleep better at night if more of my patients who come in requesting an epidural/pain medication (or really any labor intervention for that matter) have actually done their own personal research on the risks and benefits of the procedure and have made their decision based on a complete set of facts as opposed to just coming into the hospital requesting an epidural with the only “education” obtained on the matter being “my sister said she had one and it was awesome/nothing bad happened so I want one too.” Ugh!

One circumstance that I always find particularly bothersome is the fact that at many hospitals (including my own), the woman is typically signing the Consent for Anesthesia (which has to be signed with the anesthesiologist in the room) when she is extremely uncomfortable and demanding an epidural be given immediately!  So even if the anesthesiologist properly reviews all the risks and benefits with the patient, she is typically not listening, telling us she is not caring, and signing the consent without even reading it over.  Since I often feel as if I have little influence over this fact (I don’t always get the chance to show the patient the consent for anesthesia to read over when she is comfortable), I would like to take this opportunity share with all of you an actual hospital Consent for Anesthesia that is used for labor epidurals and cesarean anesthesia (including spinals and general anesthesia) so that you may read it over in the comfort of your own home and maybe even discuss it with your birth attendant and labor companions way before you ever feel your first contraction.

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

Anesthesia Consent

 

I consent to the administration of anesthesia under the direction of an anesthesiologist and to the use of such anesthetics and techniques as he/she may deem advisable.  I understand that anesthesia residents and/or certified nurse anesthetists may be involved in my care under the direction of the assigned anesthesiologist.  I understand that the type of anesthesia and/or the assigned anesthesiologist may have to be changed during the procedure due to changing circumstances.

 

The anesthesiologist has fully explained to me the risks and discomforts that may arise as a result of the proposed administration of anesthesia, as well as possible alternatives, for my labor/procedure.  I have been given an opportunity to ask questions, and all my questions have been answered fully and to my satisfaction.  The risks discussed include, but are not limited to: headache, nausea, pain, vomiting, aspiration, dental or voice injury, awareness during anesthesia, heart or breathing complications, unanticipated or prolonged hospitalization, blood clots, infections, adverse drug reactions, I.V. infiltrations, nerve damage, paralysis, blindness, brain damage, and death.  Since I am pregnant, I understand these risks extend to the unborn child I carry.  I understand and acknowledge that no guarantees or assurances have been made to me concerning the outcomes from the administration of anesthesia.

 

I confirm that I have read and fully understand the above prior to my signing.

 

____________________________________      

(Patient signature/legal representative)                        

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

Do you know what you’re signing?!?!

In conclusion, as you prepare for your labor and childbirth experience, it is very important to remember that it is ultimately YOUR OWN responsibility to become educated on your options regarding pain management, including both non-pharmacological as well as pharmacological interventions.  Likewise, waiting to “learn all about it” once you get to the hospital is not very responsible.  It is also important to remember that any pharmacological intervention, including pain medications and epidurals, carry many risks to both you and your unborn baby and therefore you owe it to your unborn baby, your partner, and all of the people in your life that love you to LEARN about it before you consent to it.  Like author Henci Goer, one of my goals in writing this blog is to never hear another women ever say, “But I didn’t know that was a risk” or “I never would have agreed if I had known that could happen.”

For fair, balanced, research-based facts and information about pain medication and epidural use in labor please check out the following resources:

 

 

 

 

_______________________________________________________________________

***As quoted on page 137 of Silent Knife by Nancy Wainer Cohen & Lois J. Estner.  NAPSAC stands for “National Association of Parents and Professionals for Safe Alternatives in Childbirth”

 

My Philosophy: Birth, Breastfeeding, and Advocacy April 25, 2009

 

I am honored, humbled, and excited to report that just a few days ago my blog had over 1,500 hits in just one day.  I was floored when I saw the number and almost choked on my Cheerios J!  When I started this blog in February I was feeling lost, frustrated, burnt out, defeated, and disempowered regarding my role in the current maternity care system in America.  The day I wrote my very first post, NursingBirth is BORN!, was only one week after I almost up and quit my job after I had witnessed a very traumatic assault and battery against a woman I was caring for as her obstetrician performed a pudendal block against her will as she and her husband were screaming for him to stop. 

 

(Side Note: This is one situation that I still have not been able to bring myself to write about.  The fact is that assault & battery on patients in health care happen DOES happen and it was the first time I had ever witnessed such an event.  I cried for days, ran the story over and over and over again in my head, wondering what I could have done differently, wishing I had the courage to throw myself over her to physically prevent him from violating her, instead of just saying “Stop!”.  I am getting pretty choked up even thinking about it so for now, I will have to continue to process that event and hopefully one day, I will be able to write about it.)

 

My intention for this blog was simple…if I could reach one mother, just one, who might stumble upon my blog and be inspired to learn more about labor, childbirth, and birth options, to realize that she has options and rights regarding her experiences and her body, I would then feel triumphant.  I had convinced myself that for months or maybe even years the readers of my blog would probably only be my husband and sister-in-law J.  I conceded to using this blog as just catharsis and a way to process my experiences.  What I never imagined was that more than just a few people would ever read, never mind enjoy and keep reading, this blog!

 

So MANY THANKS are owed to all of my readers, who have turned out to not only be moms, but grandmothers, nurses, doctors, doulas, childbirth educators, midwives, and other people in the birth advocacy community.  THANK YOU, for reading!  Thank you to those who find themselves sharing many of my interests and beliefs!!  I love networking with all of you and learning more every day about how to better serve childbearing families.  And thank you to those of you who not only disagree with me but tell me about it too!!  You keep me thinking and on my toes.  Great things come out of great discussions and a discussion isn’t quite as interesting if everyone has the same opinion. 

 

THANK YOU!  THANK YOU!  THANK YOU!

 

With all of that being said I feel that it is time to share a bit more about my personal philosophy regarding birth, breastfeeding, and advocacy.  Of course my opinions do shine through in my writing (after all, it is my blog J) but with all of this “success” (haha, take that with a grain of salt please J) I have found that many people are beginning to label me with thoughts, feelings, and beliefs that I do not hold.  Contrary to what some readers have implied, my goal in writing this blog was not to push my own agenda or to bully women into believing everything I do.  (For example, one mom linked to a lighthearted post on my blog entitled Top Ten Things Women Say/Do During Labor on a popular baby website and wrote something to the effect of “Beware of the rest of her posts because she is pretty hippy-crunchy.”  Another person commented that my blog was something to avoid because I was a “crunchier than thou/more natural than thou natural birth Nazi.”)  Please note that I am NOT writing about these comments to start a flame war, nor did they hurt my feelings (I work in L&D after all, I have a pretty tough skin!  Haha!)

 

However, I did feel compelled to outline what my personal philosophy is so my intentions are clearer in future posts and since it is my blog that is exactly what I am going to do!  I feel that it is better for me to “fill in the holes” rather than have readers “guess” at where I am coming from.  That being said, I DO NOT expect everyone in the world to share the same philosophy.  The beliefs I have written below are meant to be provocative, that is, I am not trying to hide or sugar coat anything to make it have universal appeal.  Also, although I strongly believe in these statements, I can also understand the other side of the story.  For example, although I am a supporter and advocate of spontaneous, un-medicated labor and birth as well as VBACs, I do not condemn any woman for getting an epidural, taking pain medication, or scheduling a repeat cesarean.  I know there are some people out there that would, but I do not feel that way.  In reality more so than anything else, it’s not the epidural, pain medication, or repeat cesarean that bothers me; instead, it’s the women who request these things but have never even researched their safety or risks.  Like author Henci Goer, one of my goals in writing this blog is to never hear another women ever say, “But I didn’t know that was an option” or “I never would have agreed if I had known that could happen.”  You wouldn’t believe me if I told you how often I actually hear women speak these exact words because I hear it ALL THE TIME.  Also, I would like to point out that this is not a completely exhaustive list.  Regardless, here it is!!

 

(Note: Many of these statements are taken or adapted from the following resources)

v     Childbirth Connection’s Rights of Childbearing Women

v     BirthNetwork National’s Mission & Philosophy

v     Coalition for Improving Maternity Services’ Mother-Friendly Childbirth Initiative (MFCI)

 

My Personal and Professional Birth, Breastfeeding, and Advocacy Philosophy

 

Pregnancy, Birth, & Breastfeeding

1)     I believe that pregnancy and birth are normal, healthy processes and should not be treated as illness or disease.

2)     I believe women and babies have the inherent wisdom necessary for birth.

3)     I believe that pregnancy, birth, and the postpartum period are milestone events in the continuum of life that profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.

4)     I believe that breastfeeding provides the optimum nourishment for newborns and infants which does NOT mean that I am not grateful for the advancements in artificial milk for those mothers and infants who truly require it.

5)     I believe that every woman has the right to virtually uninterrupted contact with her newborn from the moment of birth, as long as she and her baby are healthy and do not need care that requires separation.

6)     I believe that for the majority of women, VBAC (or vaginal birth after cesarean) is a safe option that should be available to all women in all birth settings who safely qualify.

 

The Obstetric vs. Midwifery Model of Care

7)     I believe that uncomplicated, healthy pregnancies far outnumber pregnancies that have complications and hence, the technology and techniques utilized to maintain the safety of mother and baby in high risk pregnancies should not be automatically or routinely applied to low risk pregnancies.

8.)     I believe that the current maternity and newborn practices in the United States that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence.

9)     I believe that although you cannot make blanket generalizations about the model of care that a birth attendant follows just by their credentials, typically speaking I believe OBGYNs tend to follow an obstetrics model of care while midwives tend to follow a midwifery model of care based on the very nature of their education.  After all, obstetricians are surgical specialists trained in the pathology of pregnancy and women’s reproductive organs.

10) I believe that per the very nature, philosophy, and experiences of medical education/obstetrical residency and midwifery education/apprenticeship, midwives should be the only health care providers attending normal, healthy, uncomplicated labors & births while obstetricians should be called to consult or transfer care to if and only if a problem or complication out of the scope of midwifery practice arises.

11) I believe that women need access to professional midwives whose educational and credentialing process provides them with expertise in out-of-hospital birth as well as hospital-based and clinical care that extends beyond the childbearing cycle.

12) I believe that midwives can obtain quality education and experience in a variety of ways and programs, including certified nurse midwifery and direct-entry midwifery. 

13) I believe that integrity of the mother-child relationship as well as the safety of our mothers and babies is compromised by the pervasive over-medicalized, obstetrics model of maternity care in this country.

 

Interventions & Natural Birth

14) I believe that research supports the reality that both a mother’s body as well as her baby will initiate the beginning of labor when the baby is ready to be born and that women should not have their labor induced for any elective reason unless the health of the woman or baby is found to be in immediate danger if the pregnancy is allowed to continue. 

15) I believe that empowering and safe births can and do take place in a variety of settings including birth centers, hospitals, and homes.

16) I believe that every woman should have the opportunity to give birth as she wishes in an environment in which she feels nurtured and secure and her emotional well-being, privacy, and personal preferences are respected, whether that be in a hospital, birthing center, or at home.

17) I believe the research supports that a minimal to no intervention, medication free, spontaneous vaginal delivery is the safest birthing option for the vast majority of both mothers and babies.

18) I believe that the obstetrical model of maternity care plus a pervasive American cultural phenomenon that teaches women to fear childbirth, doubt their innate ability and power to give birth, and be ashamed of their bodies and their sexuality is responsible for many women opting relinquish all control over their birth experiences to others and consent to unnecessary interventions that seem to provide a way to escape.

19) I believe that every woman has the right to create her own birth plan and that her birth attendants and labor companions have the responsibility to assist her in making it a reality as best and safely as they can.  I also understand that for some women, their birth plan does not include a medication or intervention free labor and childbirth and I support this as long as the women has been provided with informed consent, including all the risks and benefits of her requests.

 

Autonomy & Empowerment

20) I believe women are entitled to complete, accurate, and up-to-date information that is supported by evidenced based research on their full range of options, including all procedures, drugs, and tests suggested for use during for pregnancy, birth, post-partum and breastfeeding.

21) I believe that women have a right to make health care decisions for themselves and their babies and that this right includes informed consent as well as informed refusal.

22) I believe that interventions (i.e. many standard medical tests, procedures, technologies, and drugs including narcotic medications for pain relief in labor, epidurals, labor inductions, primary & repeat cesarean sections) should not be applied routinely during pregnancy, birth, or the postpartum period and in my opinion should be avoided in the absence of specific indications and true necessity for their use.

23) I believe that said interventions have life saving potential and are necessary in certain circumstances (which I am entirely grateful for) but are often abused and misused.

24) I believe that maternity care practice should not be based on the needs of the caregiver or provider, but solely on the needs of the mother and child.

25) I believe that every woman has the right to health care before, during and after pregnancy and childbirth.

26) I can admit that (probably related to my educational background, experiences, and values) I am not entirely comfortable with the “free-birth” or “unassisted childbirth” movement but I can also admit that I know little to nothing about the movement and I am open-minded to learning more.

27) I believe that every woman has the right to receive continuous social, emotional and physical support during labor and birth from a caregiver who has been trained in labor support and I believe that the current obstetrical education in this country does not train physicians to provide labor support.

28) I believe that every women has the right to have how ever many supportive labor companions and birth attendants of her choice (as she deems necessary) attend her labor and birth, has the right to change her mind at any time, and has the right to decline the care or presence of any unnecessary personnel during her labor and birth.

 

In closing, I am NOT anti-obstetrician, anti-hospital, anti-intervention, anti-induction, anti-epidural, anti-pain medication, or anti-cesarean.  Quite the contrary I am PRO the appropriate use of such interventions when they are necessary to support the health and safety of the mother-baby unit and facilitate a safe and empowering (hopefully vaginal) birth.  I have found my passion in assisting women and families during the intrapartum period and my number one goal in my job is to support, facilitate, and encourage a natural-as-possible, empowering, and safe birth experience, however that may be, for all those involved.

 

Thanks for reading.

 

 

The “All That Matters” Phenomenon: Grieving the Loss of a Vaginal Birth April 24, 2009

The other day I had the privilege of taking care of a couple who was in labor with their first baby.  Denise, a G1P0 at 41 weeks and 3 days, broke her water at 1:00am with contraction starting about 8-10 minutes apart at 4:30am.  She and her boyfriend, Ralph, labored at home until about 8:00am when the contractions were coming about every 3-5 minutes apart.  When she arrived to the hospital at 8:30am, a resident’s vaginal exam revealed that she was 3cm/50%effaced/-3 station!!  Since she was a young healthy woman (her health history only comprised of PCOS, or polycystic ovarian syndrome) and had had an uncomplicated, normal, healthy pregnancy, she was “allowed” to ambulate in the halls all morning but required to stay on continuous telemetry monitoring and not allowed to labor in the tub per her physician’s direct order. 

 

(Side Note:  This particular physician, Dr. O, is an older physician who is part of a group that is well known for aggressive labor management.  They induce almost all of their patients for one reason or another, often once they hit 39 weeks, and if a patient is not already ruptured once they get to the hospital, they will artificially break their patients’ water regardless of dilatation.  That’s right, I have personally refused to give them an amniohook when a patient is only 1 or 2 centimeters and they sneak in the room without me and break her water anyway!  One time, Dr. U (another doctor in that group) ruptured a patient who was still in triage!  They are notorious for setting up “post dates” inductions at 40 weeks and 1 day and although they advertise that they attend VBACs, their statistics show something quite different: Almost NO “successful” VBAC vaginal deliveries and a cesarean rate that is at least 40%.  Myself and many other nurses have bombarded them with research and position statements from a variety of sources, including their OWN association (American College of Obstetricians and Gynecologists, or ACOG)) that states intermittent auscultation is the standard of care for low risk, uncomplicated pregnancies, but they refuse to listen.  So Denise’s situation is unfortunately not uncommon.  To be honest, I am surprised they “let” her get past 41 weeks!  I think they view it as a slap in the face to attend any delivery after 40 weeks!)  

 

When I came on at 3:00pm, Denise was in the middle of getting an epidural.  Turns out that at 12:30pm, Dr. O’s vaginal exam revealed that the patient was “only” (his words) 4cm/80%/-3 so he ordered pitocin augmentation and the pit was started at 1:00pm.  Although the patient had originally told the nurse it was her plan to labor without an epidural, pitocin lead to stronger, longer, and closer contractions which lead to the patient requesting one.  And an epidural was granted.  For the next 3 hours I was instructed to continue to turn up the pitocin to obtain 5 contractions in 10 minutes.  I titrated appropriately until I obtained moderate to strong contractions (per my palpation) every 2-3 minutes, where the baby was still looking good on the monitor.  I changed the patient’s position every 30 minutes: right side, sitting up high, left side, sitting up high, etc. in hopes that I would help the baby makes his way down the birth canal and not get “stuck” in any acynclitic position. (According to the patient, she was complaining of severe back pain the last few hours so I was concerned about an occiput posterior baby.  So since Denise could no longer move herself to help move the baby, I was doing the moving for her!) 

 

At 7:00pm Denise was feeling a lot of rectal pressure, so much that she was breathing through it (even though the epidural was still effective at taking away her back and abdominal pain).  We all were very excited!!  Since Denise was only feeling rectal pressure during contractions I told her it would be best to wait until she was feeling rectal pressure at all times, with our without a contraction, before we called the doctor.  Well Dr. O must have had ESP because he came into the room to perform a vaginal exam.  His exam revealed that Denise was 4cm/100%/ -1 station!  The patient was a bit disappointed that she was still only “4cm” but I assured her that he was completely thinned out and that she had brought the baby down a whole bunch!  However, Dr. O had a different take on it, “You are still only 4cm, he said, “And if you don’t make any significant progress within the next hour we will have to talk about a change in the plan.”  (Could he have BEEN any more vague?!)  And then he turned around and walked out.  “What does he mean by change of plan?” Denise asked me.  “Well I’m not sure,” I said back, “let me go find out.” 

 

The fact of the matter is that I knew exactly what Dr. O meant….he meant that he was going to do a c-section.  But I didn’t want to tell her that for two reasons, 1) it is NOT my responsibility to tell a patient that someone else is going to perform a cesarean section on them, it’s the SURGEON’S responsibility, and 2) I hate even talking about the possibility of a cesarean section when someone is in the middle of labor because it is like you are telling the patient you are already “giving up” on them.  Of course I understand that some cesareans are necessary, but I know that if I was in her position and someone gave me a “cesarean ultimatum” during labor, I would feel like people were giving up on me!  I mean here she is, basically being given a one hour ultimatum, and because of the limitations of the epidural it is not even like she can “do” something to play an active role:  she can’t walk around or get in the tub, we’ve already got her hooked up to pitocin and an epidural, we’ve already tried the position changes, her water is already broken, and I am pretty sure she doesn’t know magic.  So here I am feeling like my hands are tied, but trying to stay positive and encouraging so that the patient does not feel upset, passive, defeated, or worried.  Because those emotions do NOT facilitate labor, and in fact, those emotions can actually release hormones in your body that directly work AGAINST labor. 

 

So I walked out to the desk to find Dr. O but he had already left.  (I don’t think he went very far, maybe into another patient’s room, but nonetheless, he was no where to be found.)  I felt an obligation to tell Denise something so I went back into to the room and said this:

 

Me: “Denise, I think Dr. O is with another patient right now but once I find him, if you would like, I can ask him to come back in to answer any questions you might have.”

 

Denise:  “Yeah, I would like him to come back in because I don’t want a c-section.”  (starting to get a bit teary eyed)  “I mean, is that what he meant by change of plan?  Can they give me any other medicine to help with my contractions?”

 

Me:  “Well I don’t know what he meant exactly but he could have meant he would like to try an IUPC which stands for intrauterine pressure catheter.  It is a thin tube that lies beside the baby’s face and actually measures in millimeters of mercury how strong your contractions are.  If I have an IUPC, I might be able to go up on the pitocin if the contractions aren’t “strong enough.”  Right now the external monitor only tells me when they are coming and when I feel your belly it is all subjective.  Unfortunately there isn’t any other medicine we can give you to help “speed up” labor besides pitocin.  He could also have meant a cesarean.  But we won’t know until we talk to him.”

 

Denise: (almost in a scared tone)  “But I don’t want a c-section!  I want to push my baby out!  Oh I don’t want a c-section!” 

 

Me:  (feeling like I wish I could help but don’t know how)  “Well let’s talk about what you can do.  If Dr. O comes in to check you, you have the right to refuse his vaginal exam and request more time.  You also have the right to ask him about all of your options, if there are any, besides a cesarean.  You have the right to ask him his reasons for why he thinks a cesarean is necessary.  You have the right to hear all that information and then take as much time as you need to decide what you would like to do.  If you need some alone time with Ralph or if you need to call your mom or any other family members you have that right.  I just want you to know that if you and Dr. O decide together that a cesarean is the best option, it will NOT be an emergency and therefore you can take as much time as you need to prepare.  The baby is not in distress and in fact, has looked beautiful on the monitor all day.   If you both decide that a cesarean is the right course of action, I promise I will go over everything to expect with you, I will make sure anesthesia sees you before you get to the OR so you can ask them any questions, and barring any other emergency, I will be with you the entire time, from the moment I wheel you in to the OR, to the moment I wheel you out of the recovery room.  I’ll help you breastfeed as soon as possible.  I will stay with you the whole time…”

 

At this point I was starting to get a bit emotional and realized I was rambling so I excused myself and went out to the desk.  I just knew in my heart what was going to happen and I was deeply saddened by it.  And don’t get me wrong, I am not trying to be overly dramatic but I just knew that when she broke her water at 1:00am and came to the hospital at 3cm, she was not expecting to end up with a cesarean. 

 

Well exactly one hour later Dr. O came back into the room to do a vaginal exam.  I turned towards Denise and I said, “Is that okay with you, Denise?” and she said “Yes.  According to Dr. O, Denise was still the same and had made no “progress.”  Dr. O, while standing at the foot of the bed, looked up at Denise and said “Well Denise, we’ve run out of options here.  If we continue to keep you on pitocin eventually the baby is going to run out of gas and crash.  Uteruses can only take so much and your uterus is going to get thinner and thinner and will be at risk of rupturing if we continue like this.  You have essentially been 4cm for 7 hours and for a primip, you need to progress at least one centimeter an hour.  We need to do a cesarean and as soon as I tell the charge nurse we’ll get going on it.”

 

At this point Denise burst into tears, “OH GOD, BUT I DON’T WANT TO HAVE A C-SECTION!  I WANTED TO PUSH HIM OUT!  I WANTED TO PUSH HIM OUT!   I REALLY THOUGHT I COULD DO IT!  I WANTED TO DO IT!  I WANTED TO PUSH MY BABY OUT!”  Ralph gave her a big hug and I kept squeezing her hand trying to bit my lip so that I didn’t start to cry myself.  She was sobbing.  And then Dr. O said “Listen, Denise, there is no reason to get like this.  I mean, when you came to the hospital this morning I also had 4 other patients that came in around the same time.  Everyone else has already delivered…you’re the only one left.  And some women even came in with cervixes more closed than yours.  You see, the baby just isn’t coming down enough in the birth canal to dilate your cervix, and it’s just a failure to progress.  It’s just failure to progress that’s all.”  Then he turned to me and said “As soon as I tell the charge nurse we’re going to go.  So then I said, “Well I am not at all ready to go yet.  And I think she deserves a minute to come to terms with all of this, Dr. O.  She deserves some time to make her decision and call her family.  And then Dr. O looked straight at me, baffled, said “Whatever” and then stormed out slamming he door behind him. 

 

I threw myself onto Denise and have her the biggest hug I could.  I whispered over and over in her ear, “You are NOT a failure Denise, I know you wanted to push him out.  I know you did.  You have done so much work today and you never gave up.  You are a strong woman, Denise, you did not fail and your body did not fail.  NOBODY is a failure here.  It’s okay to cry.  It’s okay to cry, Denise.  Please know you did so much for your baby and you never gave up.  You are a strong woman…”

 

I stayed there for about 10 minutes with her and Ralph, letting her cry.  When she calmed down a bit I encouraged her to take her time to talk with Ralph and call her mother or family if she needed too.  I told her that I needed to get some things ready and that I was going to give them some privacy.

 

So by this point I was pretty upset.  For one, I think the way Dr. O went about the whole thing was so cold and insensitive.  Um hello, do you think telling a patient that “everyone else” has already delivered is going to make them feel better!?  Because in my opinion, it just stresses the insane notion that her body is in someway a “failure.”    I could mull over and over and over again in my head everything that surrounded this whole situation and I have almost made myself sick over wondering if this was really a necessary cesarean for “true” arrest of descent/dilatation.  But regardless, I feel like he completely took Denise and Ralph out of the whole process and it should have been handled better.  Second, Dr. O did NOT go over the risks and benefits of the cesarean with them, claiming later that the residents “review that” on admission (which, by the way, they don’t…they just have everyone sign a consent for “vaginal delivery possible cesarean section”).  Third, Dr. O did not at all go over other options besides cesarean, and even if he thought the safest course of action was a cesarean at that point in time (which I am not disputing), he didn’t even say anything like “and our other options, X, Y, & Z, are not the best course to take because of A, B, C, so it is in my professional opinion that the safest course of action is to perform a cesarean section.  But please take your time to talk it over.”).  I have seen other doctors do this before.  Even in situation where everyone agrees that a cesarean is absolutely necessary, it is still the patients right to make the final decision.  And finally, he didn’t even give them a chance to talk it through and when I asked for “some time” he got pissed. 

 

So I walked out to the desk to get my paperwork ready and Dr. O was writing a note in her chart:

 

Dr. O:  (sarcastically and not even looking up from what he was writing)  “So when do you think you’ll be ready to go?”

 

Me:  (frustrated)  “It’s not about me being ready, it’s about Denise and Ralph being ready!  I think it is more than just a courtesy to allow them some time to come to terms with this new development.  They have a RIGHT to some time, Dr. O.  This isn’t an emergency.  The baby has looked great on the monitor all day and I shut the pitocin off.”

 

Dr. O:  (frustrated)  “I don’t know why you are fighting me on this!” 

 

Me:  (increasingly frustrated) “I’m not fighting you on ANYTHING Dr. O, but you have to understand, she is devastated that she is going to have a cesarean.  We owe it to her to let her calm down and not wheel her down the hall as a sobbing mess!  Her whole family lives in a different state, including her mother, and I think that it isn’t too much for her to ask for some time to call her family before she goes in for MAJOR ABDOMINAL SURGERY!” 

 

And then he said it….he said that phrase that breaks my heart every time I hear it…

 

Dr. O: “She’ll forget all about it when she is holding a baby in her arms.”

 

This phrase comes in many forms but every one says the same thing, “All that matters is that you get a baby out of this deal… and your experience, your experience doesn’t matter.”

 

Kristen, a doula, graduate student, mom, and author of the blog Birthing Beautiful Ideas wrote an amazingly insightful and moving must read post entitled, “Scars That Run Deep: ‘All That Matters’ After A Cesarean” that explores this very topic. 

 

Kristen writes:

 

“You have a healthy baby.  That’s what matters.”

 

Mothers who express sadness, anger, or disappointment after undergoing a cesarean section often hear these words uttered by (presumably) well-meaning family, friends, and health care workers.  In fact, these words seem to be one of the most common responses that people give upon hearing that a mother has had a cesarean.  I presume this is because it can be jarring to witness the juxtaposition of the joy and wonder of a newborn life and the mother’s grief over her baby’s entrance into the world.  And so, particularly in a culture that does not have a well-developed ritual for expressing and experiencing grief, people try to fill up the mother’s “empty grief jar” with an elixir of “healthy baby joy.”  But, as we all know, grief and joy don’t work like that.

 

Kristen goes on to write about why having a healthy baby isn’t “all that matters” after a cesarean, the concept of mourning the loss of a vaginal birth, and why a mother’s birth experience IS part of “what matters” regarding the entire childbirth experience.  Kristen also outlines step by step details about what a mother experiences when she undergoes a cesarean, from the minute the wheel her into the operating room to the first time she gets to hold her baby to caring for a newborn after major surgery.  Kristen writes,

 

In addition, the de-valuing of the mother’s birth experience–a de-valuing implied by the “healthy baby line”–undermines the significance of one of the most transformative days of a mother’s life.  For on the same day that her baby is born, she is “born” as a mother.  And if this dual-birth is marked by passivity and separation, then it is no wonder that the mother grieves her birth experience.  That having her healthy, miraculous, wonderful baby is not all that matters to her.

 

In fact, her sadness is partially a result of being separated from her healthy, miraculous, wonderful baby during the first few moments and even hours of that baby’s life.  And it can be the result of a feeling that her body is “broken,” “unable” to bring her child into the world on its own.  And it can be the result of a feeling that her body might not even “know” how to work properly to bring a child into the world.  And it can be the result of feeling as if she has disappointed not only herself but also her partner and/or other friends and family.  And it can be the result of the sheer difficulty of recovering from major abdominal surgery and simultaneously caring for a newborn baby, two of the most physically and emotionally demanding experiences that any person will ever undergo.

 

In other words, her sadness and her grief are understandable.  They are normal.

 

Please check out Kristen’s post in it’s entirety on her blog.  The excerpts I have provided here are only a small piece of this very eye opening composition.

 

In the end Denise gave birth to her 9lb 8oz baby boy, Rayne Nicolais, by cesarean section at 9:01pm.  Baby Rayne was found to be in an occiput posterior position and still very high in the pelvis when he was born.  I had the opportunity to stay with Denise, Ralph, and Baby Rayne for the entire experience and with the help of a ton of pillows, Denise breastfeed Rayne skin to skin in a football hold for an entire hour and 15 minutes in the recovery room.  And boy was he a vigorous breast feeder!! 

 

Although all in all, there was a positive outcome to Denise’s birth experience, I do wish that for Denise and Ralph, things could have turned out differently.  I wish that Denise could have PUSHED her baby out like she so desired and worked so hard for.  And of course I am grateful that at the end of the day Baby Rayne was a happy, healthy, chubby, bouncing baby boy.  In the recovery room where Denise really held her baby boy for the first time, she welled up, looked at her boyfriend and said, “I think I am falling in love all over again!”  It was so beautiful!  As a nurse, experiences like this solidify what I feel in my whole being is true about pregnancy and childbirth; That the journey is as important as the destination. 

 

In closing I would like to leave you with one of my favorite quotes…

 

“It’s not just the making of babies, but the making of mothers that midwives see as the miracle of birth.” ~ Barbara Katz Rothman.

 

Don’t Let This Happen To You #24 PART 2 of 2: Jessica & Jason’s Back Door Induction April 21, 2009

Continuation of the “Injustice in Maternity Care” Series

 

Please see, Don’t Let This Happen To You #24 PART 1

 

My first hour with Jessica & Jason was spent getting to know them, tidying up the room, setting it up the way I like it (I know, sometimes I can be a bit anal about clutter!  I don’t know how some nurses can work in so much clutter!!), and turning up the pitocin a couple of times.  Around 4:00pm I had left the room to scrounge around for a few more pillows for Jessica.  This took me about 10 minutes since pillows are pretty much like gold in the hospital: rare to find and very precious to have!!  Haha!  Anyways, as I walked into the room Dr. T was leaning over the trash can throwing something away and Jessica was lying flat on her back in bed, spread eagle, completely uncovered, and sitting in a big puddle.  It took me a few seconds to piece together what had happened.  Turns out Dr. T was throwing away the amniohook he used to BREAK Jessica’s water WITHOUT me being in the room!  I quickly stepped towards the bed to raise her head and cover her up.  The entire bed was soaked.  It was getting harder and harder for me to contain myself and I could feel the blood boiling up into my head. 

 

Me:  “What’s going on?”  (said in the nicest voice I could muster up)

 

Dr. T:  “Oh, are you taking care of Jessica today?”

 

Me:  “Yes.”

 

Dr. T:  “Well, I just got out of the OR and I wanted to check her progress and apparently the residents hadn’t ruptured her yet!  So I just did.”

 

Me: “Oh, well, what nurse came in here with you?  I’d like to thank her.”  (also said in the nicest voice I could muster up but clearly my sarcasm was piercing through all my attempts to stay calm)

 

Dr. T:  “No, it was just me.”

 

Me:  “Oh really, well you should have come and got me.  I would have been more than happy to assist you.  It would have liked to lay some more chux pads down under her so that when you broke her water it wouldn’t cause so much of a flood.  I’m going to have to change all the sheets now, all of them.  And what if the baby had a decel…”

 

Dr. T:  (interrupting me)  “Well I couldn’t find you.”  (turns towards Jessica)  “I’ll come back in a couple of hours to check you.”  (turns to walk out of the room and then spins around and turns towards me)  “Why is her pit only at 8mu?”

 

Me:  “Jessica didn’t even get to the hospital until 1:30 and policy states we can’t start pitocin until the patient is fully admitted.”

 

Dr. T: “Well she’s still only 4cm so you are going to have to keep going up on the pit if she is going to get anywhere.”  (This statement really takes the patient right out of the equation doesn’t it!  Outrageous!)

 

Me:  “What’s the baby’s station?  Is the baby still high?”

 

Dr. T: “Um yes, but the head is now well applied.  She’s 4cm/50%/ -3…..maybe -2.”

 

At this point all I can think of is “Liar, liar, liar!”  Dr. T turned to leave the room and after he left I assisted Jessica out of bed to the bathroom so that I could change all of her sheets and help her into a new dry gown. 

 

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

 

I need to digress for a moment to explain exactly how outrageous it was for Dr. T to check the patient and rupture her membranes without me or any other nurse in the room.

 

#1 Although this might seem like a silly thing to be upset about, the fact that he ruptured her membranes without even putting down a few extra chux pads (which were sitting right on the counter) is very rude in my opinion.  It’s like saying “You clean up my mess because I am above that.”  Honestly it wasn’t that difficult to change the bed over and help the patient into a new gown but it’s the principle of it that bugs me.

 

#2  It is an unwritten rule at my hospital that a nurse is to accompany any doctor or midwife during a vaginal exam.  Even the residents are taught this during orientation.  Is a doctor or midwife fully capable of performing a vaginal exam solo…of course they are!  But it isn’t about that.  It’s mostly about touching base with the nurse first to see how things have been going all shift with the patient.  It’s about good communication and team work.  And sometimes another vaginal exam isn’t necessary and the nurse can advocate against it!!!  I haven’t met one doctor or midwife that attends births at my hospital that has a problem with this arrangement….unless they are trying to do something that they know the nurse will question them on….like performing an early amniotomy on a patient whose baby is still high!!  The fact is that that is the ONLY reason Dr. T didn’t come and get me…because he knew that I, and many other nurses, would question the necessity and safety of such an intervention.  So he had to SNEAK it.  What he did was so SNEAKY and it infuriated me! 

 

#3  The other most important reason to obtain the assistance of the patient’s nurse (or ANY nurse at the desk really) is just in case something bad was to happen.  Although something acutely bad is unlikely to happen from just a vaginal exam, the nurse’s role in assisting with the vaginal exam is to maintain the patient’s comfort and protect the patient’s modesty.  (As you can see, Dr. T did none of those things, and things like that happen a lot with some of the docs I work with.  All of the pregnant readers I know understand how uncomfortable it is to lay flat on your back for any length of time when you are pregnant!)  But there ARE acute risks with performing an amniotomy, especially an early or prelabor amniotomy. 

 

Risks related to amniotomy that have emergent consequences include:

1)     Umbilical cord prolapse

2)     Fetal heart rate decelerations related to umbilical cord compression

3)     Change in presenting part

 

Let me give you an example.  One time I had a doctor that ruptured a patient with polyhydramnios and a high presenting part.  (That means, the baby’s head was not well engaged into the pelvis and was still “floating”.)  After the gush of water flooded the bed, the baby started to have pretty serious heart rate decelerations with every contraction related to compression of the umbilical cord.  When the doctor did a vaginal exam to check her dilation, he found that he was no longer feeling a head, but a HAND.  Since the baby was high and floating in a large amount of fluid and the head was not well engaged when he ruptured her membranes, the first thing to rush out was the baby’s hand.  The doctor was unsuccessful at moving the hand back.  And that woman, a grandmultip (G6P5) who had had FIVE previous spontaneous normal vaginal deliveries ended up with an emergency cesarean section.  And it was VERY IMPORTANT that I was in the room when all of this happened since I was the one who ended up almost single handedly assisting her into knee chest, throwing on some oxygen, and wheeling her down to the OR as the doctor rushed to scrub in.  Yes, emergencies can happen that fast.  (This one however was almost completely avoidable!!)  Please know that I am not telling this story to scare anyone.  But the LESS interventions you have, the significantly LESS chance you have of that kind of emergency happening.  And if a physician or midwife is going to take the chance with any intervention like amniotomy, it is very important that he or she has assistance from a nurse in the room. 

 

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

 

Okay, thanks for letting me rant there for a minute.  Back to the story…

 

So after I helped Jessica clean up I offered to help her out of bed into any position she liked.  After all, it’s important to use gravity to help you and not work against you!  Jessica decided that she wanted to get up into a rocking chair.  I continued to titrate the pitocin to obtain an “adequate” contraction pattern.  Jessica’s body was actually pretty resistant to the pitocin so I ended up eventually getting all the way up to “max pit,” or 20mu/min, around 6:00pm.  Jessica was contracting about every 2 ½ -3 minutes each lasting for about 40-60 seconds.  Jessica complained most about her back pain and so we tried a variety of positions to ease this for her including using the rocking chair, standing at bedside, birthing ball, back rubs, slow dancing etc.  Jason was an excellent birth coach and the two of them really worked well together.  Jessica did not feel comfortable walking in the halls (some women prefer a bit more privacy and I can’t really blame them!) so she did a lot of pacing in the room.  Around 6:45pm, Jessica was getting really tired and asked if she could get back in bed.  We tried a few positions in bed (side lying, kneeling, etc.) but the back pain was too intense. 

 

I wished at that moment we could have gotten her into the Jacuzzi but despite what some other people might tell you, trying to continuously monitor a patient in the Jacuzzi is almost impossible, especially since there are no monitors in the tub room at my hospital so I cannot see or hear what the baby’s heart rate is doing when I am in there manually holding the monitor to her belly so the bubbles don’t knock it off.  This is yet another reason why back door inductions frustrate me.  If she was in true labor and not on pitocin, I could have done intermittent auscultation which is very compatible with using the Jacuzzi.  Some women think they can have it all (for example their induction and the Jacuzzi).  But fact of the matter is that agreeing to an unnecessary induction automatically makes a natural birth plan harder, NOT impossible, but harder. 

 

Turns out the only position that Jessica liked at that time was sitting straight up in bed, leaning forward on the squatting bar, with the foot of the bed lowered so the bed looked like a “chair.”  She was moving and breathing very well in this position with Jason and me as her coaches, and she seemed to start to drift off into “Laborland.”  At 7:00pm Dr. T came into the room and stated he was going to do a vaginal exam to check for progress.  Jessica had started to complain of some intermittent rectal pressure so I had assumed that the baby had moved down some.  Turns out she was 5cm/100% effaced/-1 station!!  “This is great!,” I said to Jessica, “You are doing such a great job!  Not only are you 5cm now but you have thinned all the way out AND you have moved the baby down a lot!!  You are doing so well!!” 

 

Both Jessica and Jason seemed excited about the progress which is great because I was afraid that Dr. T would say something annoying like “Oh bummer, you are only 5 cm.”  But the truth is that in order for your cervix to dilate you have to thin out first and therefore progress in effacement and station are also signs of great progress, not just dilation. “Do you want anything for pain?,” asked Dr. T.  “No, not yet, I want to try to go longer,” she replied.  Jessica spent the next two hours sitting straight up in bed, leaning over the squat bar, with the bed in the “chair” position.  Jason was standing beside her rubbing her lower back while I was helping her to stay focused on her breathing.  She had a couple mini “freak outs” like “I can’t do this anymore!,”  “This is it, I can’t take one more contraction!”  “How much longer is this going to be?!”  What is important to remember is that these “freak outs” are NORMAL and it doesn’t mean you are weak or a wimp.  Far from it!  Labor is one of the most intensely physical experiences of your entire life.  It is comprised of sensations that are unlike any others you have felt before.  And that is why positive encouragement is so important.  I know it is hard to see someone you love in pain but Jessica had said she did not want any pain medication or an epidural at this point so providing her with unconditional support was what was needed.

 

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

A quick story…

 

When I used to run cross country in high school we would often have “distance days” were our workout consisted of running a 13-18 mile long run.  We would start right after school and often not get back until it was dusk.  Those runs were grueling especially since we lived in a very hilly town.  I remember thinking or saying things like “I can’t do this anymore!” or “No, just go on without me!”  I remember feeling so many times during those runs like I wanted to “quit” and walk.  But I knew that if I did, it was just going to take me that much longer to get home.  And one of the things that kept me going the most was the support from my teammates.  “Just run until that phone pole” then “just run to that fire hydrant” then “just run to that stop sign.”  I got through it because I took it one small stretch at a time.  When I thought about how much farther I had to go, when I thought about the whole run as a whole, the task at hand seemed overwhelming and insurmountable.  But when I took it “one phone pole at a time” I felt like I could handle it.  There was no other way to get home but to run.  And it hurt.  And the cramps in my sides made it hard to breathe.  And sometimes I would have to lean over into the woods and throw up.  Every bone and muscle ached, from my ears to my toes.  I remember my knees stinging with each footstep.  But there was no other way to get home but to run….  And when I finally crossed onto the track at the high school to run the last stretch I felt like I could do anything.  I did it! 

 

I am not trying to claim that running a long run is exactly like labor.  For one I was only running for a few hours, not hours and hours and hours.  And I knew exactly how much I had left, unlike moms in labor.  And genital pain was not involved at all!  Haha!  But the point is that a great mix of positive encouragement from my teammates, self determination, and the technique of taking it one step at a time was the reason I succeeded.  If my teammates just left me in the dust every time I said “Just go on without me!  I have to walk” then I wouldn’t have been as successful and I wouldn’t have gotten as much out of the run.  So ladies, it’s NORMAL to “freak out” a bit, which is why surrounding yourself with positive, helpful, and supportive coaches (not just “specators”) is so important, ESPECIALLY in a hospital birth.

 

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

 

Jessica labored like this for about two more hours.  She was definitely in Laborland, kinda spacey, like she was in a trance.  At around 9:00pm Jessica said that she was feeling a lot more rectal pressure and wanted an epidural so I went out to the desk to page a resident.  Lucky me Dr. T happened to be sitting at the main desk chatting with another doctor.  I told him that Jessica would like to be checked to see how far along she was because she was considering an epidural.  He came into the room and low and behold, she was 6cm/100% effaced/ 0 station.  Woohoo!  Jessica stated she wanted the epidural so I proceeded to get things set up so that we would be ready when anesthesia came in.  I had already reviewed with her the risks and benefits of an epidural earlier on (when she was more comfortable), so now I just had to explain to her what to expect from the procedure. 

 

After setting up the room I walked out to the desk to see how long it would take anesthesia to see her.  Turns out that anesthesia was tied up in a cesarean section so Jessica would have to wait.  (Unfortunately, even in a hospital that has 24/7 anesthesia like mine, they are not always available for epidurals.  So if this is your only reason for deciding to have your baby at a high-risk hospital, I would make sure you review all of your options.  And if your only labor preparation is deciding you want an epidural, it is imperative that you prepare for the possibility of not getting one!)  When I was at the desk, I checked the orders to make sure Dr. T had written for the epidural.  And that’s when I found his progress note:

 

X/X/XXXX

2115

S: Complains of more pain, wants relief

O: Cervix 6 cm dilated, completely effaced, 0 station

     EFM shows Ctx every 3 min x 60, baseline 140, +accels, Æ decels, moderate variability

A: Active phase labor with unsatisfactory progress

P:  Anesthesia notified for epidural

     Recheck in one hour, if no significant progress, anticipate primary cesarean section for arrest of dilatation

                                                                                              Dr. T

 

 

 

I was floored.  I couldn’t believe he was basically already throwing in the towel for Jessica.  It was her first baby for goodness sakes!  Babies come in their own time!  I mean, she hadn’t even gotten the epidural yet and the pitocin has to be shut off for the epidural so by the time the “hour” was up, it would have been completely unfair to expect her to have made any “progress.”  And what does that mean anyways?  So I called him out on it:

 

Me:  “Dr. T.  You are already throwing in the towel for her!?  Why does the plan even mention a cesarean at this point?!”

 

Dr. T:  “You’re kidding right, she has only changed 2cm in the last 7 hours.”

 

Me:  “Well that’s not really true because I didn’t even get her contractions into an adequate pattern until about 6pm.  And it’s her first baby.”

 

Dr. T:  “Jeeze, you call that progress?!  I can’t be here all night you know…”

 

(YES he really did say that.  This is also the doctor that told me once to tell a multip who was 8cm and feeling pushy to “Not push” because he wanted to finish the ice cream he had just ordered with his wife and kids.  I mean, I’m all for him spending time with his kids but he was ON CALL and this was a third time mom who was feeling RECTAL PRESSURE and was 8 CM!  There is NO telling her “Don’t push!”  It’s called the fetal ejection reflex for goodness sake!  And guess what, not only did he missed the delivery, but he then chewed me and the resident out for it.  I’m not making this up…In fact I can’t make this stuff up!)

 

Me:  (getting pretty upset but trying not to scream at him)  “Are you kidding me!  She wasn’t even in labor when she got here!  If she was, you wouldn’t have started her on pitocin.  She wasn’t even in labor!  You didn’t have to be here at ALL but YOU were the one who sent her in for induction.”

 

Dr. T:  (smirking)  “Induction!  She was 4cm!”

 

Me:  “But she couldn’t feel any of her contractions!  And now you are just going to cut her without at least seeing if the epidural helps?!  This is her first baby!  This delivery has consequences for the rest of her life!”

 

I was afraid I was going to strangle him at this point so I just left the desk to go back into the room.  Anesthesia didn’t show up until 10:30pm and at 11:00 pm Penny, the night nurse, came in to take over.  I stayed until the epidural was finished and tucked her in.  The next day I got the full scoop on what happened from Penny and the patient’s chart.

 

Apparently Jessica got great relief from the epidural and slept like a rock for 2 hours.  Luckily the baby tolerated the epidural well and remained happy on the monitors. Dr. T must have fallen asleep in his call room or gotten distracted because he never came back to check her.  At 1:30am Jessica woke up feeling a lot more rectal pressure.  Penny called the resident to check her and her exam revealed she was fully dilated (HOORAY!!) but that the baby was still at a 0 station.  Since the resident was busy with other patients she agreed, per Penny’s request, to NOT call Dr. T and wake him up but rather to shut off the epidural, allowing it to wear off a bit, and use passive descent to help get the baby down more before they started pushing.  (Although Jessica was feeling more rectal pressure, a practice push revealed that she could not feel her bottom enough to push.  If she had started to push at that time, she would have just tired herself out).  Also, Penny knew that Dr. T was notorious for only “letting” patients push for about an hour (even if they can’t feel their bottom) and then if the baby isn’t out he performs a cesarean for “failure to descent.”  Phooey! 

 

One hour later at 2:30am Jessica was feeling an uncontrollable urge to push and a vaginal exam by the resident revealed that she was 10cm/100%/ +2 station!!  Yay!!  Penny said that she felt it was best not to make Jessica wait for Dr. T to rise and shine so she instructed Penny to push whenever she felt she needed too.  She said that Dr. T didn’t even make it into the room until about 10 min before Jessica pushed out her 8lb, 6oz baby boy at 3:05am after only approximately 30 minutes of pushing!!!!  The baby was also found to be in an occiput posterior position, which explains all that back pain Jessica was experiencing and perhaps the length of her labor as well.  Dr. T did cut an episiotomy but the baby delivered before he could get his hands on a vacuum J.  According to Penny, baby Christopher James nursed like a champ and stayed skin to skin with mom for almost a whole two hours! 

 

Fortunately for all those involved, Jessica and Jason’s story had a wonderful ending!  However, despite the fact that Jessica’s birth did not end in a cesarean section doesn’t mean that there were not many injustices in the way her care was managed by her birth attendant.  Stories like this always get me thinking…what if?  What if Jessica had been sent home from the office instead of sent in for a back door induction?  Would the baby have eventually turned around so that he was no longer occiput posterior?  Would her natural contractions been easier to handle and therefore would she still have opted for the epidural?  If she was not induced with pitocin and therefore not required to be on continuous monitoring, would the freedom to move around more in labor and the ability to use the Jacuzzi tub helped to alleviate her back pain if the baby stayed occiput posterior?  What if she had had a different nurse that encouraged her to get the epidural earlier on?  What if Dr. T had gotten his way and started to make the patient push before she had regained use of her legs and feeling in her bottom?  What if Dr. T had kept her membranes intact until much later in the labor?  What if Dr. T had checked her one hour after she was found to be 6cm and she hadn’t made “satisfactory progress”….would she have been given a cesarean for “failure to progress?” 

 

In summary, I would just like to say that unlike what many OBGYNs, nurses, friends, family members, moms, journalists, etc will tell you, the journey matters just as much as the outcome.  The fact is that women truly amaze me no matter how they give birth.  Whether it is a natural home birth or a scheduled cesarean section, the bottom line is that women have superpowers!  They can grow people inside of them after all!!  And my greatest wish is that all women will feel in control of the decisions regarding their birth and in the end feel empowered no matter the mode of delivery.  But as a society we have to be more conscious of how our overly medicalized maternity care system affects the thoughts, feelings, and emotions of our patients and families as well as their outcomes.

 

Don’t Let This Happen To You #24 PART 1 of 2: Jessica & Jason’s Back Door Induction April 13, 2009

Continuation of the “Injustice in Maternity Care” Series

 

Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!”  Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  If haven’t already read it, I invite you to check out the first addition to the countdown: DLTHTY #25: Sarah & John’s Unnecessary Induction

 

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

There are so many things about the current state of maternity care in the United States that frustrate, infuriate, sadden, and annoy me but one particular thing that really gets my goat is the back door induction.  As you might have already read, I am a labor & delivery nurse in a large urban hospital and we are BUSY!  Although I know there are hospitals that way more deliveries a year than we do, for the capacity of our hospital, 4500 deliveries a year is almost more than we can handle with our current facility and staffing.  (By the way, 4500 deliveries a year breaks down to about 375 deliveries a month and about 12 deliveries a DAY!  (Jeeze, I am exhausted just looking at the statistics!) 

 

One way to help organize all the chaos is to have an induction book in which doctors have to schedule all of their inductions at least 24 hours in advance.  This way we have somewhat of an idea about appropriate staffing and room assignment for our patients for each day (in theory).  (The exception to this rule is the induction in which there is a documented medical reason related to either mom or baby’s health that requires an urgent delivery of the baby.  For example, severe intrauterine growth restriction (IUGR) with a non-reassuring nonstress test (NST) and biophysical profile (BPP) or worsening preeclampsia.  We obviously don’t make these mom’s sign up for a spot.  They are usually a direct admit from the office to the hospital.) 

 

However, when a doctor is either lazy, anxious, rushed, or overall feels he is above the rules, he (or she) will send a patient in from the office as a direct admit to the hospital for labor when she actually is NOT in labor and will the proceed to INDUCE her under the guise of augmentation.  When providers do this, it increases the amount and acuity of our patient census and puts an unnecessary strain on our staffing which compromises the amount of individualized care we can give to our patients.  What these doctors don’t tell you is that inductions can take up to three days to complete!  If you are truly in spontaneous natural labor, even a slow labor, you won’t be in the hospital for 3 days.  Inductions take MORE time, MORE money, MORE staff, MORE resources and hence are MORE risky.  Let’s digress for a moment so that I may clarify the difference between induction and augmentation:

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

 

Labor: Regular, noticeable, and painful contractions of the uterus that result in dilation (opening) and effacement (thinning) of the cervix.  Therefore if you are having regular uterine contractions that are noticeable or even painful but are not making any change to your cervix, it is NOT labor.  Likewise if your cervix is dilated and effaced but you are NOT having uterine contractions that are noticeable and painful then you are NOT in labor.  (Note: I have had low intervention doctors and midwives send multips (a woman who has given birth at least once) home at 4 or 5 cm if they are not having any contractions or not changing their cervix.  One particular patient I can remember was a G5P4 and was 5cm dilated when she came to the hospital.  We kept her for 4 hours but she never changed her cervix…she couldn’t even feel her irregular contractions and she was comfortable.  So she was sent home.  Two weeks later she came back 8cm dilated in hard labor and I assisted with her very quick birth.  She did amazing and the baby was happy and healthy!  Clearly, even at 5cm, she wasn’t in labor.)

 

Induction: the use of medications or other methods to start (induce) labor before the woman’s body has spontaneously begun true labor on its own.

 

Augmentation: stimulating the uterus with medications or other methods during labor that has already begun naturally to increase the frequency, duration and strength of contractions, the goal of which is to establish a pattern where there are three to five contractions in 10 minutes, each lasting more than 40 seconds. 

 

So just to be clear (and to adequately set up my story) if a woman is 4cm dilated but is not having regular, noticeable, and painful contractions that are causing cervical change she is NOT in labor.  If said woman is sent into the hospital and any interventions to stimulate contractions are started, then it is by definition considered an induction NOT an augmentation.  And if said patient was not scheduled to be admitted on such day, then it is considered a backdoor induction.   

 

Let’s continue with the story…

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

 

It was a Friday morning before my weekend off and I came in to work at 11am as usual.  I was looking forward to the weekend since it had been a really busy week and I was exhausted.  For the first four hours of my shift, I triaged a few patients but ended up sending them all home for one reason or another.  As I was finishing up some paperwork at the desk around 1:00pm, Dr. T came off the elevator and over to the nurses station.  I overheard him telling the charge nurse that he was just at his office and was sending over a primip (a woman who has never given birth) for us to admit for labor who was 4cm dilated/50% effaced/-3 station by his exam in the office.  He then slinked towards one of our second year residents who, in my opinion, will definitely be joining the ranks of the aggressive labor management elite, and uttered, “I’m sending over a patient from the office, 4cm.  Could you break her water when she gets here and start her on pit.  I know you’re the only one who will do it.  The baby is still high.”

 

Situations like this one are exactly the reason why I shouldn’t eavesdrop!  The reason why Dr. T was concerned that “no one else” would break her water was that when a baby is at a minus 3 station and is “too high,” if the membranes are ruptured artificially the umbilical cord could slip down before the baby’s head, getting pinched between the baby’s head and the cervix, cutting off all blood flow from the placenta to the baby.  This is called a cord prolapse and it is a surgical emergency requiring an emergency cesarean section.  This emergency is very unlikely if your water breaks naturally at term during labor because typically when it happens naturally the baby’s head is well applied to the cervix which puts pressure on the bag causing it to break.  I wanted to turn around and shout at Dr. T, “If you are so concerned “no one else” will take the chance, why won’t you do it yourself?!  Is it really so wise if it is so unsafe?”  Furthermore, the thought of sending over a patient for “labor” and then immediately starting her on pitocin and breaking her water makes my head feel like its going to explode!  If she is really in labor then she does NOT NEED pitocin!  And if she “needs” pitocin, then she is NOT in labor!  This is a BACK DOOR INDUCTION and ladies, it happens all the time.  Think about it, it was a Friday and Dr. T happened to be on call that weekend.  Looks like he didn’t want to get a page over Sunday brunch that one of his patients was in labor!  AHHHHHHHHHHHHHHHHH! 

 

Sorry, I lost it there for a minute J.  But it is just these kinds of injustices that make my blood boil!  Let’s continue…

 

Come change of shift at 3pm I was patient-less since I had sent all my triages home and hence was assigned to the patient in room 9.  And guess whose patient it was!  None other than Dr. T’s “labor” patient!  Oh brother!  This was going to be an interesting night! 

 

From report I got most of the details:  Jessica was a 25 year old first time mom (G2P0) just a few days past her “due” date (40 weeks and 3 days).  Here health history was unexceptional: exercise induced asthma as a child that did not require any medications, tonsillectomy at age 7, and one miscarriage at 5 weeks two years ago.  Her pregnancy was normal, healthy, and uncomplicated.  The patient had arrived to the hospital at 1:30pm with her longtime boyfriend Jason.  Jessica’s day shift nurse had completely admitted her and started her on pitocin but because the floor was crazy busy all day, she had only gotten the pitocin up to 4mu/min and the residents had only gotten the chance to write orders and not to rupture her membranes.  (My thought = Yes!!)  [Note: For a description of how pitocin is administered check out: Don’t Let This Happen To You #25 PART 2: Sarah & John’s Unnecessary Induction].

 

Next I went into the room to meet Jessica and Jason.  Jessica was a bubbly young woman with big rosy cheeks.  Her boyfriend Jason was living proof that you can’t judge a book by its cover.  He was super funny and down to earth and very supportive of Jessica in every way, yet a bit intimidating at first because he was almost completely covered in tattoos and had multiple facial piercings J.  They looked like total opposites and yet were so perfect for each other.  We chit-chatted for awhile and really seemed to hit it off since we all had the same sense of humor.  I took the opportunity to satisfy my curiosity about how Jessica had ended up in the hospital since she seemed very comfortable the whole time we were talking.  The monitor strip revealed that she was having contractions about every 6-8 minutes but she was not even flinching as I saw them come and go on the monitor.  To gain a bit more information I started to ask some questions.  I kept the conversation light in tone, like “So tell me about your day today?” instead of “Why the heck are you here!  Run!  Run away!!”  J  Here’s our conversation:

 

Me: “So how did you end up at the office today?  Did you have a scheduled appointment or were you having contractions?

 

Jessica: “No I was feeling great!  I had a scheduled appointment and when they put me on the monitor for a non-stress test, the nurses told me that I was having contractions!  It was so crazy because I didn’t even know I was having them!  So then Dr. T decided to check me since I was contracting and I was 4 centimeters!”

 

Me: “Can you feel any of your contractions now?”

 

Jessica:  “I think so, well, am I having one now?  Wait, no, maybe now?  (Looks towards monitor) Yeah, I am having one now.

 

At this point I’m thinking: If you have to look at the monitor then the answer is no, no you are not feeling contractions!  Sometimes I turn the monitor screen off so the patients or family members can’t “contraction watch.”  J

 

Me: “So what happened next?  Did Dr. T tell you to come right over or did he say you could go home first?”

 

Jessica:  “He said we could go home first and get our stuff together but not to “dilly dally” because they were waiting for us here.  So we rushed home and grabbed our bags.  Good thing we packed last week!”

 

Me:  “Yeah, it’s great you were prepared.  What did Dr. T tell you the plan was for when you got here?”

 

Jessica: “He said that once we got here that he would break my water but they haven’t done that yet.  I guess it’s really busy today, huh?”

 

Me:  “Yeah, It’s a busy day.  Did he say anything about starting you on pitocin?”

 

Jessica:  “He mentioned that I might ‘need a little pitocin’ because my contractions weren’t in a regular pattern and were pretty far apart.”

 

Me:  “I bet it was a big surprise to you to be induced today, huh!”  (I couldn’t help myself!)

 

Jessica:  (confused)  “Well I didn’t expect to find out I was in labor today  that’s for sure!”

 

Me: “Do you guys have a written birth plan or any thing I should know about regarding your labor and birth preferences?”

 

Jessica:  “No nothing written.  Well, I wanted to try to go as natural as possible.  I don’t want any narcotics and I don’t think I want an epidural.  I mean, I’m not ruling it out, but I really want to go as naturally as possible……………I mean, I guess that’s not totally going to happen now because I am on pitocin but, well, you know…”

 

(Yes!  The “in” I’ve been waiting for! Sometimes I wish I could tape patients and then play back what they say to me to see if once they hear it back, they then realize how illogical their doctor is.  I mean sometimes I feel like a mom who has to sneak spinach into her kids’ favorite foods to trick them into eating vegetables.  I can never just come out and say my intentions, I have to play this “game” and hope they figure it out themselves.  This is something of a daily internal struggle for me.)

 

Me:  “Well that is not necessarily true because although we are limited by the fact that with the pitocin running I have to have you on the monitors, as long as I can trace the baby’s heartbeat I can help you into any position that makes you most comfortable.  Unfortunately pitocin is not a good as the “real” thing you know? What I mean is it makes contractions artificially stronger and longer than natural contractions.  But I will do my best to titrate the pitocin so that we get an effective labor pattern that both you and the baby can tolerate well.  We can all work as a team, sound good? J

 

Jessica & Jason: “Yeah sounds good!”

 

I’m sure, my savvy reader, you have already recognized why I started this post with the difference between induction and augmentation!!  The TRUTH is: If you are at term and someone has to “tell” you that you are “in labor” then you are NOT in labor!  I just feel so badly for these women!  I truly don’t think it is their fault!  I think that they put all their trust in their birth attendant and most of the time are just naïve and don’t know any better.  And I don’t say that to be patronizing, I say it out of love and concern.  And as I mentioned in the first post of this series, I don’t want to start off my first interaction with these patients by going off on a tangent about unnecessary induction because I don’t want to make them defensive, doubtful, untrusting, or upset because these emotions do not facilitate labor!

 

*Sigh* 

 

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

 

Up For Next Time: Don’t Let This Happen To You #24: PART 2 of 2 

 

Read about Jessica’s labor, the birth of her baby, and Dr. T’s upsetting prediction about her birth too early in the game.

 

 

(Research for this post was aided by my trusty OB textbook from nursing school:  Maternal-Child Nursing (Second Edition) by Emily McKinney, Susan James, & Sharon Murray Ó2005)