Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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

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

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

Dear Nursing Birth,

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Sincerely,

Kelly

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Dear Kelly,

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

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

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

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

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

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

 

I couldn’t agree more!

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

Sincerely,

NursingBirth

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Urgent Message from ICAN! Please Spread the Word!! October 18, 2009

Filed under: In The News — NursingBirth @ 10:07 AM
Tags: , , , , ,

Hello Everyone!

 

Please check out an urgent message sent from Gretchen Humphries, the Advocacy Director of the International Cesarean Awareness Network (ICAN).  She needs our help to spread the word and send in stories about a most critical healthcare issue:  insurance discrimination.

 

For more information on this story please check out ICAN’s website.

 

Thank You,

 

NursingBirth

 

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From: Gretchen Humphries <advocacy@ican-online.org>
Date: Fri, 16 Oct 2009 1

Subject: Urgent request for stories

 

I have sent you this request because of your connections within the Birth
Community. I hope that you will see if there is any way you can assist ICAN
with this request.

 

We have made this request before but now the stakes are really high. Peggy
Robertson
is a woman from CO who testified yesterday before the HELP
committee (the Senate Health Education Labor and Pensions Committee) about
being denied coverage because of a previous cesarean, unless she could prove
she had been sterilized. (We managed to work in a couple of comments about
VBAC bans too! Which got some response from a couple of Senators!)
Senator Mikulski, who chaired that hearing, has asked for more stories
similar to Peggy Robertson’s. Please distribute this request as widely as
you can –

 

ICAN needs stories about discriminatory insurance practices based on a
previous cesarean. This can include but is not limited to demands for
sterilization, restrictions on how soon you can have another pregnancy and
be covered, higher premiums, restrictions on the total amount of benefits
they will pay, excessively high deductibles for maternity care. Even if all
you have is your name, state, contact information (email is fine) and a
description of the circumstances (with the name of the relevant insurance
company(ies) if possible) we can use it. If you have written documentation,
that would be pure gold.

 

There is interest about this at the highest levels of the Federal Govt. and
we will use this to open the discussion on other areas of discrimination
(like VBAC bans, lack of transparency, etc)….so please, take a moment and
get the information to ICAN. You can email me at advocacy@ican-online.org
or you can snail mail to ICAN of Ann Arbor, PO Box 48, Stockbridge, MI
49285.

 

Your story could make a difference that would improve the care available for
millions of women and their babies.

 

Thank You,

 

Gretchen Humphries
Advocacy Director, ICAN
advocacy@ican-online.org
(517) 745-7297

 

Natural VBAC Hospital Birth: One Reader’s Empowering Experience September 3, 2009

Dear NursingBirth,

  

I wanted to share with you my birth story.  I thought since I did an all natural VBAC, it might be something you would want to share.  Thanks for the posts.  YOUR blog helped me get though my second birth! Your stories of inspiration that you have are amazing, and just your general  tone.  The fact that there are nurses out there like you made me have the confidence to trust the nurse with me, but also not be totally trustworthy. It helped me realize that I am the final decision maker.

 

In preparing for my VBAC I read your Injustice in Maternity Care Series and your story “I Needed to Know My Body Could Do It!”: A VBAC Story over and over.  I also read Active Birth by Janet Balaskas which I think helped me a lot, and with our first daughter (my c-section) we took Bradley classes so we both thought we were so prepared.  This time I had my mom, a friend and my husband as my birth team and we took control, which reading about it from your point of view gave me the courage to do so!!!


Thanks for all you do!  I love the blog!

 

Sincerely,

Katie C.

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Dear Katie C.,

 

I would LOVE to reprint it and am honored that you would even send it to me!  Thank you for reading and THANK YOU for being such an awesome and empowered woman and mother!!  It is women like you that are an inspiration to ME!

 

I just love everything about your birth story!!  First off, CONGRATULATIONS on your VBAC and on the birth of your daughter!!  What a wonderful time for you and your family!  It also must be really nice to NOT have to recover from major abdominal surgery and take care of a newborn and 3 year old!  Second, one HUGE pat on the back to you for choosing to go back home during your initial trip to the hospital when you were found to be 2 centimeters.  That took A LOT of courage and trust in your body and your abilities, especially since the on-call doctor was pressuring you to stay.   And I completely agree with you; choosing to labor at home until you were more “active” most definitely had a significant impact on your successful unmedicated VBAC.  Thirdly, KUDOS to you for being an active participant in your birth!!  It no doubt helped your labor progress to be upright and moving during your labor!  I am so proud of you!!  While it’s true that no one can really “plan” their birth, you did everything you absolutely could to stack the cards in your favor!!  Yay!  Yay!  Yay!!!

 

Thank you again for reading and sharing!

 

All My Best,

NursingBirth

 

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Katie C’s VBAC Birth Story

College Station, TX

 

Starting on Friday, May 22, I started having very mild but consistent contractions at 5 minutes apart at lunch time.  The rest of the day they came and went, some getting farther apart but stronger slowly as the day went on.  I also had a lot of brownish and pinkish spotting.  Figured that maybe I was in very early labor.  Did my usually stuff that day and went to bed about 9:00pm, just in case this was it. Saturday morning I woke up about 1:00am with contractions strong enough that I couldn’t sleep.  I got up and ate some peanut butter toast and drank a bunch of water and tried to go back to sleep.  Contractions were about 7 minutes apart but stronger and enough so that I was having a hard time sleeping.  Likely because I was excited.  Got up and took a bath but that didn’t help.  Tried to go back to sleep.  Got up and ate 2 huge bowls of apple cinnamon cheerios.  Finally fell back asleep about 4:30 am.  Woke up at 7am and was just very tired.  Contractions were completely bearable but figured that we were starting (maybe) and so I had Madison go to Jaxson’s (and George and Amie) house for a few hours while my mom and I stayed home to see if anything would progress.

 

Lamaze International's Tips for a Normal Birth #5:  Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

Lamaze International's Tips for a Normal Birth #5: Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

 

As the day went on they got stronger but not really closer.  I called L&D and she said 3-5 minutes apart, not able to talk through them, so I just figured I would wait.  Wasn’t ready to go to the hospital yet anyway.  I called Meredith (a friend), who was working about 2 hours away, to let her know that she might have to come back that night. We decided that she would come back that night instead of waiting for a call at 2:00 am and have to drive then.

 

Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

 

My back started hurting and I called another friend of mine who does massage. She wanted me to come to her studio, but I really didn’t want to leave the house, so I decided to stay home. Rob called his mom and went to meet her and take Madison to her house so that we wouldn’t have here with us. By the time Rob got back, about 6:30pm, contractions were 5 minutes apart and getting stronger. I could still talk and walk, but it took effort. I called Meredith back and she said she was on her way to my house. At 7:30pm I started to panic.  The contractions seemed very strong to me, I was concentrating on them and they were consistently 5 minutes apart, so we decided to head to the hospital.  I called Meredith and told her to meet us there.  Once I got there, my contractions stopped pretty much, likely due to my nerves.  They got me into a room and set and checked me and I was 2cm and 80% effaced.  I was devastated!  I told them I wanted to go home.  The doctor on call was leery of that since I was a VBAC and they said they would really like me to stay but I refused and we packed up and came home.  (In hind site, this was the reason it all worked out!! Best Decision!!!)

 

 

I went to bed disappointed and tired, since I had been contracting for nearly 30 hours at this point and I just wanted to either be in labor or not.  I ate a snack and went to bed.  At about 3:00am I was woken by very strong contractions, 7 minutes apart, strong enough that I would flip to hands and knees in bed and rock and moan through them. Rob decided I was in labor, though I was still not sure!  LOL!  I started just sleeping in between them.  (Must have been some natural coping mechanism, since I did it until about 6:30 am!)  We started timing for real at 7:00am.  Meredith came over and she helped my mom.  My mom would time the start to start and Meredith would time the duration. They were about 5 minutes apart with about 30 seconds of what I would call pain.  The actual contraction would last about a min or longer.

 

 

As the morning went on, I could no longer do anything during the contractions except hang onto Rob and moan.  Contractions got stronger and longer.  They were 4-5 minutes apart, and lasting (pain) about 70 seconds.  During one contraction while I was hanging on to Rob I had a huge rushing feeling, almost like a pushing sensation (or so I thought) so I just said, “We have to go NOW!” We packed up and went up to the hospital.  I had 4 contractions in the car, which were the hardest ones!  [At that point I preferred to be standing during them, since sitting or lying down was excruciating.] We got back to the hospital and I was moaning and hanging on Rob and everyone in the ER was looking at me funny.  It made me laugh.  They probably all thought I was crazy!  

 

 

I went back up to L&D and they put me in the same room and got me all set up again.  The nurse said, “We were waiting for you!” I was so nervous that I would only be 3 centimeters and they wouldn’t let me go!  She checked me (about 11:00am) and I was 6cm, fully effaced!!!  I cried when she told me, I was so happy!!  Rob, Mom and Meredith clapped!  LOL!  They told me I had to stay.  I said that was fine!  They put me on the monitors and said I would be able to get off of them, but then the Dr. on call said “NO!” so I was worried I would be stuck in bed.  The nurse said, “You can move as much as you want, so long as the cord is long enough,” so I got out of bed and stood next to it for most of the day.  We said I didn’t want to be checked again except by the doctor or if they thought I was complete (i.e. pushing) so when the doctor got there at 1:00pm she checked me and I was a stretch 8!! I was still concerned that it wasn’t going to happen, but everyone else was excited.

 

Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

 

Transition for me was the second hardest thing I have ever done.  I refused pitocin (which they really didn’t push since I was a VBAC) and did not let them break my water. I stayed at a 9 centimeters for almost 3 hours, then at 9 ½ centimeters for a while until I begged them to stretch my cervix!!  LOL!  I was on the bed with the back raised on my hands and knees and suddenly had a contraction that felt better when I kinda of pushed at it. My mom went to get the nurse and she tried to check me like that but said I really needed to lie down.  I said I didn’t want to push lying down and she said, “Sweetie you can push however you want, but I need to make darn sure you are complete so you don’t swell.” I knew that was true so I got down and she checked me and then had the doctor come in and doctor said, “I’d call that complete!” I was so freaking happy! However I was also exhausted and once I was lying down, though I was hurting, I just couldn’t get back up again.  They broke my water sometime in there.  [I think it was earlier when I was at a 9 ½ centimeters but I can’t remember.]

 

 

The first few pushes I really thought I was doing it but I think the contractions were just not strong enough.  I actually asked the doctor how far down Hana had to be to use the vacuum!  I was exhausted!  The doctor said that she wasn’t going to use the vacuum, so I was just going to have to push!  I started pushing about 4:45 pm.  She would come down (once I finally figured out just how freaking hard you have to push!!) and then scoot back in.  They explained to me that a little bit of pitocin would help to bring the contractions a little closer together, so I would be more effective in pushing, since I was having over a minute between them and Hana would just scoot back in.  I finally agreed to it at about 5:45pm.  The started it at about 6pm.  The doctor suggested a pudendal block, in case I needed an episiotomy (which while I wanted a natural tear, I wasn’t against at that point and I never thought I would come through it with no tear or cut).  I even got a mirror to see my progress, and knew right then that something was going to have to give! I made them put the mirror away!

 

 

I started pushing 5-6 times per contraction and the doctor had been with me the whole time.  She had them break the bed and get all the stuff ready and I asked “Is she coming out this way?” and the doctor laughed and said, “I’m not doing a c-section today!” She asked me also if I wanted to feel Hana’s head, but I just couldn’t bear the thought for some reason.  I kept pushing and finally she said, “Ok, this next one you’re going to have your baby!” and so I hauled back and pushed harder than I thought possible and her head popped out and I kept pushing (oops!!) and Hana was born Sunday May 24th at 6:28pm!!!  It was the most amazing thing in my life and no doubt pushing was the hardest thing in the world.

 

Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

 

They gave her to me and after a few minutes (she was breathing but a little blue still) they took her over to rub her and clean her up some.  I was shaking so bad at that point that Rob had to hold her. I ended up with a 4th degree tear… not from her head, but her shoulder popped out when I pushed and the doctor wasn’t expecting it, and so that’s that.  But it isn’t so bad!  She stitched me up, and while it is sore, it beats the hell out of a c-section! Right after she was born I said, “I had a baby out of my vagina!” much to the amusement of the nurses and pretty much everyone in the room! But I can’t tell you just how amazing it was for me. I had been waiting 3 years for that.  And now I have it!  Hana was given back to me and she latched on right away and nursed like a champ for 15 minutes on each side (I was STILL being sewn up!) and finally Rob and Hana went off to the nursery.  To our surprise (and the doctor’s too) she was 8lbs 1 oz, 19 inches long.

 

Happy Birthday Hana!!!!

Happy Birthday Hana!!!!

 

 

I am recovering very well and almost feel like new!!

 

For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

 

Don’t Let This Happen To You #23: Alona & Dmitry’s Unnecessary Repeat Cesarean Section April 29, 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.

 

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

 

I was recently part of what I consider to be an absolutely unnecessary repeat cesarean section and a true example of what I consider the “control phenomenon” in today’s maternity care culture.  This very real trend stems from the fact that obstetricians (trained surgeons who are the only birth attendants capable of performing a cesarean section) have professional motivation and incentive to promote and perform interventions that only they can provide, hence increasing their control (e.g. vacuum or forceps deliveries and cesarean sections) as well as discourage and lobby against choices in childbirth that decrease their control and increase the control of the childbearing family (e.g. homebirth, natural/unmedicated birth, and VBAC).  After all, any properly trained birth attendant can attend a VBAC (including midwives and family practice physicians) but ONLY obstetricians can perform cesarean sections.  In their groundbreaking book Silent Knife: Cesarean Prevention & Vaginal Birth After Cesarean, authors Nancy Wainer Cohen & Lois J. Estner describe this phenomenon,

 

“Cesareans are done for many reasons.  In addition to the legitimate ones, they include power, control, money, fear, and prestige.  However, we believe that the most important reason is that most physicians totally lack understanding and respect for women and for birth.  [Routine] Repeat cesareans are done for the same reasons, with risk of uterine rupture the excuse for this deplorable crime.  Vaginal birth after cesarean (VBAC) is not only safe, but generally safer than its alternative.  In spite of the research and evidence and documentation that appear on this subject, most obstetricians in this country continue to perform repeat cesareans simply because a woman has been previously sectioned.  There is always an excuse, it seems, why a woman cannot be a candidate for VBAC.  We know that most women who have had a cesarean are capable of delivering vaginally.  This includes women with a diagnosis of cephalo-pelvic disproportion (CPD), prolonged labor (failure to progress), or more than one previous cesarean.”

 

Now that the stage is set, let’s begin the story…

 

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

 

It was a beautiful and sunny weekend morning and I arrived to the hospital, changed into scrubs, and punched in at 11:00am as usual.  As I was looking over the patient assignment sheet, a young Russian** couple came to the desk.  Both had very thick accents and it was quickly evident that the husband spoke better English than his wife.  The husband described a “large gush of water” that fell all over the floor as she was making breakfast.  The young woman stated that she had put a towel in her pants that was now “very wet” and that she started having “pains” about 10 minutes after the leaking started, which happened to be around 10:40.  While at their house they then called their doctor who instructed them to come right to the hospital since, if she did break her water, she was going to be sent for a cesarean section today because she had a history of a previous cesarean section.  (In fact her “repeat” date was scheduled for the next week where she would be 39 weeks in gestation.)

 

I was asked by the charge nurse to escort the patient and her husband down to one of the triage rooms near the operating room (OR) (just incase she was indeed ruptured) and to pass her off to another nurse who would be waiting for her there.  I introduced myself to both the woman and her husband and asked the woman if she wanted a wheelchair.  She declined and although she was very quiet, almost stoic during our short journey, I could tell by her walk that she was very uncomfortable.  After I gave the woman a gown and assisted her into the bathroom, I told all I knew to her nurse Sally and went back to the main desk. 

 

For the next hour I was unassigned to any patients so I spent that time assisting other nurses.  Around noon I was assisting a fellow nurse whose patient was delivering when I got called out of the room by the charge nurse.  “We’ve got to run two rooms in the back and I’m going to need you to be ‘baby nurse’ for Dr. W’s case, the patient in room 2.” 

 

(Note: At my hospital we have three operating rooms on labor and delivery.  We try our best to only run one room at a time, if urgency and time allows us, since running two rooms can really put a strain on the staff.  To run two rooms at the same time you need 6 nurses total, three for each room (a scrub nurse, a circulating nurse, and a baby nurse).  The scrub nurse actually scrubs into the surgery and assists the surgeon by passing him/her instruments and sutures.  The circulating nurse usually is the nurse that knows the most about the patient and her job is to coordinate procedures and ensure the patient’s safety and comfort.  The “baby nurse” assists the anesthesiologist with administering anesthesia, preps the patient for surgery, and the gowns up to “catch” the baby from the surgeon, and then brings him over to the warmer to assess him.  Even though we have an OR team Monday through Friday during the day shift, between running the OR, staffing the recovery room, and admitting the next case, the OR team doesn’t always have enough nurses to run two rooms and in that circumstance the charge nurse has to pull nurses from the floor.  Therefore if we were running two rooms, I knew that something must be happening with one or both of the cases that increased their urgency.)

 

I grabbed my OR hat and mask and walked down towards the OR to talk to the circulating nurse and re-introduce myself to the patient (something I try to do if at all possible before they enter the OR).  The circulating nurse, Sally, was at the desk and gave me a very abbreviated report, “Her name is Alona.  She is a G2P1 at 37 weeks and 6 days and her first baby was delivered via cesarean for ‘failure to progress/failure to descent’ per her prenatal summary.  Her husband, Dmitry, told me that the doctor told them the reason she needed a cesarean the first time was that his wife’s ‘vagina was too small.’  They are both graduate students at XU.  She’s got an unremarkable history.  She’s scheduled for a repeat cesarean next week so we’re going to the OR.  We’re gonna move in about five minutes.” 

 

As I walked into the patient’s room, I quickly realized why everyone was rushing around…the patient was huffing and puffing through her contractions.  She was still on the monitors at this time and I noticed that her contractions were coming every 2-3 minutes with nature as the only influence acting upon them.  As I stuck out my hand to re-introduce myself to the couple I had escorted here not one our ago, I realized that the patient was uncontrollably grunting and pushing at the peak of her contractions.  At this point the circulating nurse came in to administer her pre-operative antibiotic, followed by the anesthesia resident who started to unplug the bed from the wall.  My mind was racing…this woman is in LABOR!  This woman is PUSHING!  Why is everyone ignoring this?!  At this point the anesthesia resident and the circulating nurse started to wheel the patient out of the room and I was having none of that! 

 

Me:  “Sally, she’s pushing.”

 

Sally: “What?”

 

Me: “She’s pushing!  We need to get her checked.  We can’t wheel her back there like this.”

 

Sally: “We just checked her 20 minutes ago and she was 5cm/90%/0 station.”

 

Me: “Was she pushing 20 minutes ago?”

 

Sally: “Well no but…”

 

Me:  “Well then I don’t care how long it has been since you last checked her!  We need a resident in here to check her!!!”  (Note: At our hospital, because we have residents, we are actually not allowed to check our own patients even if we have the skills to do it!  I am not exaggerating.  The head of the residency program feels that if nurses check their own patients then residents won’t get enough “experience.”  Therefore new nurses are not even taught how to perform a vaginal exam during orientation.  I feel that this is absolutely absurd and just another way the OBGYN department attempts to maintain the utmost control over all situations.  But I digress…)

 

At this point Sally poked her head out of the door and motioned for the resident to come in.  I was holding Alona’s hand and trying to coach her breathing, in, out, in, out, in, out…

 

Me:  “Alona, we are going to do a quick vaginal exam to make sure the baby isn’t coming, is that okay?”

 

Dmitry (the husband):  “The baby can’t come out!  Her vagina is too small!”

 

Me:  “Sir, it’s going to be okay.  Every baby is different.  Her vagina is not too small.”

 

And then the resident said the most OUTRAGEOUS thing I have ever heard…

 

Kate, the resident: “She’s 8cm/100%/ +1 station and that’s without a contraction.  If we don’t get her to the back right now, she’s going to have this baby!  Let’s go!”

 

[Have you ever watched a show and the cartoon character does a “double take” where they shake their head really fast back and forth and it makes a sound like something is rattling in their head?  I swear I did that when I heard the resident say that and I actually said out loud, “WHAT?!!?  That is ridiculous!”]

 

Me:  “Kate, we’ve got to get Dr. W in here to talk to her.”

 

Kate: “Dr. W wants to do a cesarean.”

 

Me: “Yeah, but don’t you think it’s more important to do what the patient wants?!  I think circumstances have changed enough to where someone should reevaluate this situation with her!”

 

[Kate left the room to go talk to Dr. W, as I think I made her really uncomfortable by calling her out and bringing up the patient’s needs.  God forbid!!  I poked my head out of the room to hear his answer.]

 

Kate: “Dr. W, she is 8/100/+1.  Should we counsel her about a vaginal delivery?”

 

Dr. W: (really frustrated and almost offended at even the thought) “NO!  We’re doing a repeat!  WHAT ARE YOU WAITING FOR, GET HER TO THE BACK!”

 

(Note: “The back” is hospital lingo for the operating room)

 

On that note Sally and the anesthesia resident continued to wheel her out of the room and through the double doors to the operating room.  At this point I really thought I was going to start to cry.  There have only been a few times that I have cried at work (I’ve cried a lot more at home!) but this situation was really hitting a cord with me.  As we were wheeling the patient down the hall I looked at her and her husband and said, “Alona, you are 8 centimeters.  You do not have to have surgery if you do not want to.  This is your choice.”  Alona just stayed silent, and kept looking at her husband.  Perhaps this was a cultural thing, perhaps she was scared, perhaps she was too much in the throws of transition to hear any word I was saying.  We entered the OR at 12:30pm.  Sally and the resident pushed the bed up against the OR table and instructed the patient to move over.  Again, I held onto Alona’s hand, looked her in the eye, and said, “Alona, it’s not too late.  If you need more time to think about things we can give it to you.  If you want to talk to Dr. W about your options we can do that.”  Then I looked at Dmitry and said, “Dmitry, she is 8 centimeters now.  We do not have to do this surgery if she want to try to have the baby vaginally.”   But Alona just kept looking at her husband (who was allowed in the OR at this point because we needed him to help translate since Alona kept throwing down the language line phone during a contraction!) and he looked back at me and said “No, the doctor said she must have surgery!” 

 

And you know what?!  I don’t blame them one bit for not even listening to me.  After all, I am essentially a stranger, perhaps some kooky nurse to them whom they have never even met, while Dr. W was their “trusted” doctor.  If he couldn’t take (or didn’t want to take) the time to come in and talk about their options, then why should they listen to me!?  I found out after the surgery, when I looked back into Alona’s prenatal summary and previous OR report, that Alona’s first cesarean was performed after a 2-day “failed induction” to where she only progressed to 3cm/50% effaced/ -3 station.  A thorough review of the patient’s first OR report revealed a classic “cascade of interventions” including elective induction at 40.2 weeks with an unfavorable cervix for “postdates,” early amniotomy and pitocin administration after one cervidil placement, epidural for pain relief, fetal scalp electrode and intrauterine pressure catheter placement, and eventual cesarean section for “failure to progress/failure to descent.”  Although I support women’s rights, patient autonomy, and choices in childbirth, if the only thing that Alona & Dmitry learned from their last delivery was that her vagina was “too small,” I highly refute any claim by ANYONE that this patient was provided with true informed consent and an honest debriefing on ALL the factors that did or could have contributed to her last cesarean section. 

 

As I was assisting the anesthesiologist with the spinal by trying to keep a woman in transitional labor still (not an easy task), Dr. W burst through the OR doors, hands wet from scrubbing, and exclaimed in a most joyous way as he peered up at the clock on the wall, “Oh excellent!  I can be out of here by half past one at the latest and still make it to my golf game!” 

 

AAAAAAAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!!!!!!!!!!!!

 

YES!  HE ACTUALLY SAID THAT!  AND THE PATIENT WAS AWAKE WITH HER HUSBAND IN THE ROOM! 

 

After that I pretty much turned my emotions off; I couldn’t handle it and I had to focus on the task at hand.  “Open” time for the surgery was 12:45pm.  Alona & Dmitry’s baby boy was born at 12:50pm.  “Close” time was 1:16pm.  As soon as the last staple was placed, Dr. W ripped his gown off, thanked the resident and anesthesia, said a quick “Congratulations” to Alona & Dmitry, and bolted out of the room, leaving the resident as the only OBGYN to escort the patient out of surgery and write all the orders. 

 

I gave the baby Apgars of 7 & 9 but at about 7 minutes old he started to have a  bit of a difficult time clearing his secretions and his oxygen saturation started to dropped so I had to suction him a couple of times.  The scale showed the baby weighed 7lbs, 3oz.  When it was time to leave the OR, I wrapped up the baby and walked out with the patient and her husband.  I had to keep him on the warmer in the recovery room for only about 10 minutes, basically, the time it took the team to hook her up to the monitors, do a fundal (“belly”) check, and give her some pain medication.  I then put the baby skin to skin with Alona under her gown and his vitals stabilized quite well after that. 

 

All in all despite the fact that Alona, Dmitry, and baby all appeared to be happy and healthy after surgery, my personal belief is that they were victims of medical malpractice and the current unjust maternity care system in this country.  I know malpractice is a loaded term but I think it describes the situation very well: “mal” = bad practice.  That is one of my biggest concerns with the rising rate of scheduled repeat cesarean sections.  Once the date is set it’s like everyone has blinders on;  the excuse “But she is scheduled for surgery” doesnt mean she qualifies for it now!  For one, consenting a patient for major abdominal surgery PRE-LABOR in the office and treating it as the absolute only course of action regardless of what situations might arise to the contrary is WRONG.  I can safely bet that when Alona “agreed” to a repeat in the office that she was mislead into thinking or mistaken that things were automatically going to go exactly the way they did last time .  I can safetly bet that she did not expect to show up to the hospital after going into labor spontaneously and progress from 5 to 8 centimeters in a matter of 20 minutes when she was “counseled” (term used VERY lightly) about her options and “consented” (again, used lightly) to a repeat cesarean section months before.  And you know what, if she had shown up at 10 centimeters with a head on the perineum I KNOW that her doctor would have STILL rushed her off to surgery even so because I see it happen at work ALL THE TIME.  It’s outrageous, it’s meddlesome, it’s arrogant, it’s tragic, and it’s untrusting of a woman’s natural and innate ability to push her own baby out!!

 

In their Patient Choice Cesarean Position Statement, the International Cesarean Awareness Network (ICAN) writes,

 

“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.

 

All physicians take an oath to “Do no harm”. This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.”  

 

The fact of the matter is that I do not believe that Alona’s c-section was necessary and I believe that her doctor did do her harm by performing her surgery without at least revisiting her options with Alona before he ordered for her to be wheeled into the operating room.  She needed to hear and deserved to hear her options from Dr. W at that time and not anyone else.  Although the above position statement was written regarding patient choice elective cesarean section, I feel that it also pertains to elective repeat cesarean sections since I do NOT believe that “prior cesarean section” is an automatic indication that is well supported in the literature as being a good enough reason to just schedule another major abdominal surgery.  I agree with author Norma Shulman as she was quoted in the book Silent Knife, “Those who favor repeat cesarean because of its ‘ease’ and ‘safety’ need to be reminded that ‘all the factors that make cesareans so safe nowadays also serve to make VBAC safe, and more rewarding.”  To me, many other childbirth advocates, and to thousands and thousands of women in this country, the birth of a child is not the only goal of labor, it’s a very important one, but it’s not the only one.  Women aren’t just “fetal vehicles” and their experiences in labor and childbirth have profound effects on their self-esteem as well as their relationship to their partners, their babies, and their families for the rest of their lives. 

 

Are you pregnant and have a history of a previous cesarean section?  Did you know that you have the right to informed consent and informed refusal regarding repeat cesarean section vs. VBAC?  Did you know that there are resources out there to help you?  Please check out:

 

(1)  ICAN’s Cesarean Fact Sheet

(2)  ICAN’s Vaginal Birth After Cesarean (VBAC) Fact Sheet

(3)  Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean by Nancy Wainer Cohen & Lois J. Estner

(4)  DON’T CUT ME AGAIN! True Stories About Vaginal Birth After Cesarean (VBAC) by Angela, J. Hoy (Editor)

 

And find a local ICAN support group near you!

 

 

**As always, all identifying information including names, dates, times, ethnicity, etc. have been changed or omitted to protect privacy and adhere to all HIPPA guidelines.

 

Birth Resources EVERY Woman Should Know About April 23, 2009

I was at my local ICAN (International Cesarean Awareness Network) meeting yesterday and the theme for the night was “Birth Stories.”  Although I have never had a cesarean section, attending the local ICAN meetings is, for me, a way to get together and work with other people in the birth advocacy community and meet pregnant moms who are seeking out more information regarding their birth choices.  Anyways, throughout the meeting last night I found myself often referring to different books that I have read that I feel are great resources for pregnant moms.  Everyone else seemed to jump on the bandwagon and by the end of the night, I think all the gestating members of the group had heads that were spinning with tons of different information!

 

This meeting inspired me to put together a list of books, websites, and movies that I have personally read or watched that I feel are “must see/must reads” for any woman who is trying to get pregnant, currently pregnant or newly postpartum.  Whether you are planning a homebirth birth with a direct entry midwife or wishing you could have your OBGYN call in your epidural before even getting to the hospital, these resources are something to seriously consider.

 

It is important to note that this is an abbreviated list.  I have so many amazing books on pregnancy, childbirth, and breastfeeding that it’s kind of ridiculous.  But I made sure to keep this list brief for a reason; I don’t want to scare anyone away!  I don’t want anyone to think “Oh jeeze, there are just too many things on this list.  I am too overwhelmed to read any of them!”  That being said, if there is any book, movie, website, etc that you found or are finding to be very helpful with your past or current pregnancies, I’d love to hear about it!!!

 

MUST READ BOOKS:

 

*Best Childbirth Preparation Book*

Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation by Pam England & Rob Horowitz

 

*Best “How To” Guide to Helping a Woman Through Childbirth*

The Birth Partner, Third Edition: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions  by Penny Simkin

 

*Most Inspiring/Positive/Empowering “What To Expect” Book*

            Ina May’s Guide to Childbirth  by Ina May Gaskin

 

*Best Practical Guide to Breastfeeding*

            So That’s What They’re for: Breastfeeding Basics by Janet Tamaro

 

*Best “Research that Doesn’t Read Like Research” Book*

            The Thinking Woman’s Guide to a Better Birth by Henci Goer

 

 

 MUST WATCH MOVIES:

 

* Best Hard Look at the Current State of Maternity Care in America

The Business of Being Born (2007)  Directed by Abby Epstein, Produced by Ricki Lake

 

*Most Personal Documentary About Being Pregnant In America

Pregnant in America: A Nation’s Miscarriage (2008)  Directed by Steve Buonagurio

 

 

MUST SEE WEBSITES:

 

* ICAN (International Cesarean Awareness Network)

– ICAN’s mission is to prevent unnecessary cesareans through education, to provide support for cesarean recovery, and to promote VBAC.

 

* Coalition for Improving Maternity Services (CIMS)

– CIMS is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Their mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.

– CIMS is the founder of the The Mother-Friendly Childbirth Initiative  and The Birth Survey

 

* Citizens for Midwifery

– Citizens for Midwifery (CfM) is a non-profit, volunteer, grassroots organization. Founded by several mothers in 1996, it is the only national consumer-based group promoting the Midwives Model of Care.

– CfM can help you learn about the Midwives Model of Care, find a midwife in your area, and connect with resources about birth and midwifery

 

* La Leche League International (LLLI)

– La Leche League International strives to help mothers worldwide to breastfeed through mother-to-mother support, encouragement, information, and education, and to promote a better understanding of breastfeeding as an important element in the healthy development of the baby and mother.

 

* BirthNetwork National (BNN)

– BNN is is leading a grassroots movement based on the belief that birth can profoundly affect our physical, mental and spiritual well-being.

– BNN has local chapters and holds monthly meetings all around the country!

– BNN believes that:

· Birth is a normal, healthy process, not an illness or disease.

· Empowering births can take place in birth centers, hospitals and homes.

· Women are entitled to complete and accurate information on their full range of options for pregnancy, birth, post-partum and breastfeeding.

· Women have a right to make health care decisions for themselves and their babies. That right includes Informed Consent as well as Informed Refusal.

           

 

So now it’s your turn!  What books or other resources did you find helpful when preparing for pregnancy, labor, birth, and postpartum?  We all want to know J!

 

Top 8 Ways to Have an Unnecessary Cesarean Section April 3, 2009

(Adapted from Top 7 Ways to Have an Unnecessary C-Section)

 

Happy April everyone!  As you may or may not be aware, the International Cesarean Awareness Network (ICAN) has declared April to be Cesarean Awareness Month.  In honor of this, I decided to share with you a website I recently found that I thought was pretty amusing. 

 

Blogger Esther Brady Crawford of faintstarlite.com recently wrote a post entitled “Top 7 Ways to Have an Unnecessary C-Section”.  Not only is it amusing (and perhaps a bit cynical) but it is also: 1) sad that it is so true and 2) very true.  I encourage you to read her original post since she gives her own hilarious explanations for each “pointer” but since I am a big research nerd, I have added my own comments to her original Top 7.  At the end of this post I have included an eighth “pointer” to the list to make it a Top 8.  Much of the research I cite in this post is from the book The Thinking Woman’s Guide to a Better Birth by Henci Goer.

 

So here it goes…

 

#7  Go the hospital in the early phases of labor.

          Crawford is just plain right-on with this one!  Too many obstetricians are quick to label a mom as having “dysfunctional labor” if she does not progress at least one centimeter an hour (for first time moms) or two centimeters and hour (for multiparous moms) immediately upon arriving to the hospital.  I have even had some doctors I work with take a call from a mom at home that “sounds like she is in labor” and turn around and tell the residents to “start her on pit as soon as she gets here.”  WHAT??!!  Pam England, CNM, MA writes in her book Birthing From Within, “One advantage to laboring in the privacy of your home, with one-on-one midwifery support, is that should a problem arise that requires medical support at the hospital, you will not wonder whether your labor problems were caused by routine, unnecessary, or ill-timed hospital interventions.”

 

#6  Don’t eat or drink during a long labor.

          Goer writes that dehydration and starvation caused by restricting food/drink intake during labor causes a woman not only considerable discomfort but can also lead to fever, prolonged labor, increased use of oxytocin (aka pitocin), instrumental delivery, and a non-reassuring fetal heart rate pattern/fetal distress.  And what can all of these lead to…that’s right…a cesarean section!  (Goer, 79-83)

 

#5  Get an amniotomy too soon.

          Amniotomy (or artificially “breaking the bag of waters”) too soon can lead to umbilical cord compression/fetal distress, abnormal fetal heart rate patterns, cord prolapse (a surgical emergency where the umbilical cord slips out into the birth canal before the baby’s head), increased likelihood of maternal infection and hence a “race against the clock” to get a woman “delivered” before 24 hours is up, and lastly, a greater chance that the baby get “stuck” in a posterior (back of head toward your back) or acynclitic (head tilted off to one side) position which can stall labor and make pushing at best, difficult and at worse, unsuccessful.    Bottom line, if it ain’t broke, leave it alone!  Not obeying that rule could lead you to an unnecessary cesarean!  (Goer, 99-104)

 

#4  Accept pitocin to induce or stimulate contractions.

          The use of oxytocin (pitocin) for labor augmentation (aka “revving up a slow labor”) or induction (aka artificially starting a labor that hasn’t started on its own) has its own risks.  Although oxytocin is quite effective at stimulating contractions, it often makes contractions stronger and longer than natural contractions, can cause too many contractions too close together (aka uterine tachysystole or hyperstimulation) which can lead to fetal distress, can double the chances of a baby being born in poor condition, and eventually can lead you to the operating room!  (Goer, 65)

 

#3  Request an epidural.

          Research has shown that epidurals 1) interfere with a mother’s natural release of labor hormones which can in turn (among other things) slow or stop her progress of labor, 2) increase her chances of needing pitocin augmentation for said slowed labor, 3) numb her pelvic floor muscles, which are important in guiding her baby’s head into a good position for birth , 4) can cause maternal fever than can be mistaken as a sign of infection, 5) can cause a significant drop in her blood pressure which can interfere with how much blood supply is getting to the baby and can lead to profoundly negative effects on the baby’s heart rate, 6) significantly impair in her ability to push her baby out effectively.  All of these side effects/risks, as research has shown can, and often does, lead to a cesarean section.  (See “Epidurals: risks and concerns for mother and baby” by Dr Sarah J. Buckley)

 

#2  Accept hospital staff’s comments on lack of progress without challenge.

          In my opinion, nothing is more detrimental to a woman’s labor progress and ultimately her birth experience than negativity in the labor room from labor & birth attendants, especially the people who are the “professionals” like obstetricians, midwives, and nurses.  As Marsden Wagner, MD, MS writes in his book Born in the USA, fear and anxiety stop labor.  And giving a woman the impression that she is “failing” can lead to a helpless and hopeless attitude and eventually a cascade of interventions that might very well lead to a cesarean section. 

 

#1 Just ask!

          Believe it or not, there are some OBGYNs out there that will agree to perform a cesarean section on a first time mom without medical indication.  Goer writes, “Popping up lately in the medical literature are arguments that women should be able to have first cesareans for the asking as well.  Again, this is presented as a freedom of choice issue.  But how much real freedom do women have in a culture that portrays labor as torture and C-sections as a ‘no muss, no fuss’ option?”  Goer states that the obstetric belief that choosing between a cesarean and vaginal birth is like choosing “between chocolate and vanilla” is really about six things: money, impatience, convenience, peer pressure, hospital culture, and defensive medicine.  What I find even more disturbing than this, however, is that women who do desire to avoid a cesarean and plan for a vaginal birth after a cesarean (VBAC) are finding themselves with less choice and opportunity to do so in more and more communities around this country as more and more obstetricians are refusing to attend VBACs and hospitals are either banning or placing de facto bans on VBACs.  

 

And lastly here is my own addition…number 8!

 

#8  Agree to a labor induction without medical indication.

          Induction of labor comes with risks and the BIGGEST risk is the risk of cesarean section.  When induction of labor is done for a medical reason, either related to mom or baby, and the risks of continuing the pregnancy are greater than the risks of induction, then this is the only time when labor induction is appropriate and warranted.  But when a woman agrees to a labor induction without any medical reason, then she is putting herself at risk for an unnecessary cesarean section, plain and simple. 

          Many obstetricians I work with claim that all the “elective” labor inductions (that is, inductions without medical indication) are because the woman “demands” it.  And don’t get me wrong, there are some women out there who are a bit mislead.  But all to often a woman shows up for a labor induction and it is overwhelmingly obvious that she: 1) wasn’t fully explained both the benefits AND risks of labor induction, 2) wasn’t told that labor induction can take up to three days to complete, 3) wasn’t told that comfort measures like using a jacuzzi tub or shower, walking, using the birthing ball, eating, drinking, and general freedom of movement are MAJORLY restricted during labor induction either because of hospital policy, obstetrician’s philosophy, or the requirement of continuous external fetal monitoring, 4) didn’t realize she had the option to say NO.

 

So there you have it, the Top 8 ways to have an unnecessary cesarean section.  I wish it wasn’t true but unfortunately it IS!

 

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

 

“We have a secret in our culture, and it’s not that birth is painful; it’s that women are strong.” ~ Laura Stavoe Harm

         

 

“I Needed to Know My Body Could Do It!”: A VBAC Story March 26, 2009

Last week I had the honor to be a part of one of the most beautiful VBAC (Vaginal Birth After Cesarean) hospital births I have ever witnessed. I would like to share that couple’s story with you today as both a feel-good tale of personal triumph and a story of inspiration for all those moms planning a VBAC out there that might stumble upon my blog. Since this is a blog about “a nurse’s view from the inside” this story is probably much different than any other birth story you might have read from the mother or father’s point of view. But then again, maybe that isn’t so bad! Enjoy!

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It was ten to 11 o’clock am as I walked through the lobby doors of the hospital I work at, rushing towards the elevator so I could punch in on time. As the elevator doors started to close, a hand shoved through the crack, forcing the doors back open. “Please make room!” said the woman, a phlebotomist who works in the hospital, in a shaky voice, “Woman in labor here!!” Following behind was a very pregnant woman, huffing and puffing as she waddled into the elevator, followed by what looked like her husband and her mother. “Don’t touch any buttons!” said the phlebotomist, “We’re going right up to labor & delivery!” Since that was where I was headed too, I smiled at the husband and said, “Don’t worry, you’re here now and she won’t have the baby in your car! I work up on L&D so I’ll show you were to register.” Something told me that if this woman was truly in labor then she would be assigned to me since I was just starting my shift. But she had to “pass” triage first, so after helping the family to the registration desk, I hurried into the locker room to change into my scrubs.

Fifteen minutes later the triage nurse came to the main desk, “I’ve got a term mom, 40 weeks 5 days, who’s five centimeters,” she said, “We’re gonna need to put her in a room…. And she’s a VBAC with a ‘birth plan’.” “I’ll take her!,” I said excitingly, knowing that I have my best days when I can assist a woman through labor, as opposed to getting stuck on the OR team or in the high risk ward running magnesium. (Not that those women don’t need a lot of TLC too, it’s just that I like labor the most!) Birth plans, natural unmedicated labor, and getting my patients out of bed…those are my specialties! I quickly set up the room across the hall as the resident finished the patient’s history and physical in the triage room. Then I quietly knocked on the triage room door and let myself in. The patient, Alyssa*, was standing by the bed, rocking her hips back and forth, as the continuous monitors strapped to her abdomen traced the baby’s heart rate and her contraction pattern. It looked like she was contracting every 3 minutes, and the baby’s heart rate was beautiful and reassuring. Her husband, Jared, was leaning nervously against the wall and her mom, Deb, was sitting quietly in the corner. I could really tell that Alyssa was lost in “Laborland” and I wanted to make the transition to her room as seamless as possible as to not break her rhythm and concentration too much. I quietly introduced myself and with the help of Jared and Deb, moved all of their belongings across the hall as Alyssa waddled behind.

I could tell that Alyssa was coping well with the contractions while standing but a quick glance at her prenatal summary revealed that she was Group B Strep positive and would need IV antibiotics (our hospital’s policy) and hence, and IV. Now I feel that I am pretty skilled at starting IVs, but I have not yet mastered starting an IV with the patient standing and swaying! So in the two minutes between the contractions, I explained to the Alyssa what I needed to do before the admission process was complete: get 5 more minutes of continuous monitoring on the baby (to equal the “20 minute strip” my hospital’s policy requires before we can switch to intermittent auscultation), take a set of vital signs, draw three tubes of blood, start an IV, and ask a few more questions. “Give me 8 minutes sitting on the bed,” I said, “and I can have everything but the interview done. The rest of the admission can be done with you standing up.” “Okay,” she said, “I can do eight minutes.” Eight minutes later the IV was in, antibiotic running, labs drawn and sent, vital signs done, monitors were removed, and the patient was helped out of bed (Phew!! That was close!! J). And it wasn’t a moment too soon because Alyssa was having a lot of back labor and sitting in bed was just making it worse!

Then there was a knock at the door. Here’s how the subsequent conversation went down…

Me: “Who is it?”

Med Student: “It’s just the medical student,” (said as he walked right into the room)

(I hadn’t yet gotten a chance to ask Alyssa if she was okay with medical students so I just kind of looked over at her and Jared and tried to judge their reaction.)

Med Student: “Hi I’m Michael. I have to ask you a few questions.”

(Have? How about “Is it okay if I ask you a few questions? Sheesh!!)

Med Student: “Are you being induced today?” (asked as he stared down at his paper)

Alyssa: “INDUCED! DOES IT LOOK LIKE I AM BEING INDUCED!”

Med Student: “Okaaaaay. Umm, any problems with this pregnancy?”

Jared: “Do you really need to ask these questions right now? The resident already asked her that stuff.”

Med Student: “Umm yeaaaah, I do. There is a lot of repetition but we have to ask again.”

Deb: “Doesn’t her prenatal summary tell you all of that?

Med Student: “Ummmmm….”

Me: “With all do respect, Michael. But I think they are trying to tell you that they do not want any medical students. Or anymore residents for that matter. Okay? So I think we are done here.”

Med Student: “Ummm, what am I supposed to tell the resident?”

Me: “Tell her I said that the next induction that comes in is all yours.”

As the med student left, Jared, Deb, and Alyssa all looked at me simultaneously and said “THANK YOU!” “I don’t think he was getting the hint,” said Jared. “Yeah,” I said, “I figured he needed it spelled out.” In hind sight, I think this was one of the moments that really helped me to bond with this family because after all, I understand how difficult it must be for families to come into the hospital and have to work with a nurse that they have even never met during one of the most intimate experiences of their lives!

I spent the next fifteen minutes finishing up the patient’s admission assessment as quickly as I could. I told Alyssa that if she was having a contraction to just ignore me, and asked Jared to help answer any questions he knew the answers to. (Unfortunately, our hospital’s pre-registration does not include performing an admission assessment and hence, it has to be done on arrival to the hospital. Usually, if a patient comes in for false/early labor a time or two, it gets done then but Alyssa had not been to the hospital her whole pregnancy, which is great, but it meant that I did have to bother her with some silly questions during labor. Kind of a bummer, but with the help of Jared, it went pretty smoothly.) It was during the admission interview that I found out some of the details of Alyssa’s pregnancy and prior cesarean section. Alyssa had an unremarkable health history and a normal, healthy, uncomplicated pregnancy. She was a G2P1, but since her first baby was born by cesarean section, she technically was considered to be a “primip” (healthcare slang a woman who is about to deliver her first baby) regarding a vaginal delivery.

Jared told me that when their son was born two years ago, Alyssa was persuaded into an induction at 39 weeks for “LGA” (a.k.a. large for gestational age, which by the way is NOT recognized as an appropriate indication for induction of labor by ACOG), was first given a few doses of misoprostol to “ripen” the cervix, followed by pitocin to stimulate contractions and continuous external fetal monitoring to monitor those contractions, then given a couple doses of Stadol and eventually an epidural for the pain, followed by artificial rupture of membranes to place a fetal scalp electrode after the epidural dropped Alyssa’s blood pressure and caused a prolonged fetal heart rate (FHR) deceleration, then an intrauterine pressure catheter to assess if the pitocin induced contractions were “adequate”, and eventually a cesarean section after 1 hour of pushing in a back-lying position for “failure to descent & cephalopelvic disproportion (CPD).” Thirty minutes later baby Kevin was born at approximately 2:00am, weighing in at 7lbs, 5 oz.

In my opinion, Alyssa was a victim of the “cascade of interventions.” Many maternity interventions, including elective induction, pain medication, artificial rupture of membranes, epidural anesthesia, back-lying positions for labor or for birth, etc. have unintended effects. Often these effects are new problems that are “solved” with further intervention causing a domino effect that ends up creating yet more problems. This chain of events has been called the “cascade of intervention” and unfortunately often leads to vacuum extraction/ forceps delivery, episiotomies or 3rd or 4th degree tears, and even cesarean section. Many of these women are often also then mislabeled with diagnoses like “CPD,” “failure to progress,” “failure to descent,” and at the end of it all, the obstetricians turn around and say, “Thank God we were in a hospital; look at all the technology we needed! So when will your repeat cesarean be??”

This time, however, things were different. After the birth of their son, Alyssa and Jared started to research more about labor and birth, VBAC, and natural birth. They interviewed and chose a doctor (Dr. Z) that was supportive of natural birth and VBACs, with the statistics to prove it! And here they were now, at my hospital, ready and rearing to go! Alyssa said that for the past few days she had been having contractions “on and off” but that they really started to get going at 8:00 am. When the resident had checked her on admission, her water spontaneously broke during the vaginal exam at 11:15am. It was now 11:45am and Dr. Z’s midwife entered the room. Although it had only been 30 minutes since her last vaginal exam, the midwife decided she would check Alyssa again since she seemed pretty active. And boy was she ever! The midwife’s exam showed that Alyssa had progressed to 7-8 centimeters! “I don’t think I can do this anymore,” Alyssa softly whimpered to the midwife. We all reassured her that she was doing so well and that things were getting more intense for a reason and to stick with it!!

The midwife then offered to help Alyssa into the shower to help alleviate her back pain. Alyssa seemed skeptical at first but we assured her that if it wasn’t helping, that we could get her right back out. So Alyssa agreed and the midwife and I, along with Jared, helped the patient into the shower. What happened for the next hour was one of the most beautiful displays of love, perseverance, hard work, and dedication I have ever witnessed. Alyssa turned her back to us and rested her hands on the grab bar on the shower and her head on the shower wall. Her cadence was this: Between contractions she would sway side to side, as if she was slow dancing. During contractions she would squat up and down, up and down, moaning in a low tone as she carried out her ritual. She just moved with the rhythm of her labor, listening so instinctively to what her baby and her body were telling her to do. Jared used the hand held shower head to spray Alyssa gently with a stream of warm water up and down her body, concentrating mostly on her lower back. I quietly entered the bathroom a few times that hour to check the baby’s heart rate with the portable doptone, trying hard not to disturb Alyssa’s concentration. Mostly, however, the midwife, her mother, and I stayed outside the bathroom door as to give Alyssa & Jared the privacy they needed to facilitate the progress of her labor.

At 12:35pm Alyssa told me that she was starting to feel a strong urge to push. The midwife entered the room and as Alyssa knelt in a hands and knees position in the tub, the midwife checked her cervix. To everyone’s surprise Alyssa only had an anterior lip of cervix left to go (this means she was about 9 ½ centimeters dilated)! After the next contraction, Jared and I helped Alyssa out of the shower to the toilet where we both used warm towels to dry her off. Then Alyssa walked over to the bed, “Can I kneel on my hands and knees?” she asked. “Sure!” we all said in unison, as we helped her up onto the bed. “I feel like I have to push!” Alyssa said convincingly and when the midwife checked her cervix, the anterior lip was gone…Alyssa was fully dilated at 12:45pm, only 1 hour and 55 minutes after arriving at the hospital! “You can start to push anytime,” said the midwife.

One of the best things about being a part of this experience was the fact that it was one of the only times that I have been present at a delivery where that a birth attendant has allowed the mother to use spontaneous or mother-directed pushing, as opposed to directed pushing. I knew that Alyssa was interested in using a variety of pushing positions for the second stage of labor from her birth plan and for the next hour and a half the midwife, Jared, Deb, and I helped Alyssa get into a variety of positions including right/left side lying, squatting, hands and knees, and kneeling.

(Side Note: I would like to digress for a moment to point out how important it is to be physically fit during your pregnancy whether you are planning for a natural birth or not. Many a woman I take care of blindly fills out a “birth plan” they find online where they can click on the boxes for options that sound “good” to them, without actually researching or thinking over what they are writing down. For example, they say that they want to try squatting during labor and birth, but couldn’t even do a squat at the gym pre-pregnancy. Although it is definitely true that a woman can sum up and realize an incredible amount of strength during labor and birth related to not only hormones but also sheer will power, it should also be known that labor is HARD WORK and pushing out a baby is HARD WORK which both require a great deal of physical strength and stamina. This is yet another reason why it is so important to follow a modified exercise plan and eat a healthy well balanced diet rich in protein and omega-3 fatty acids before, during, and even after your pregnancy.) Let’s continue with Alyssa’s story…

What was so amazing was that although there were plenty of times during the labor and pushing phase that Alyssa would doubt her ability to go on (“I can’t do this anymore!” “The baby isn’t moving?” “Is the baby moving?” “I am so tired!”), she never gave up on herself. Each time she made a comment like that, we all took it as a request for more support. And every time we gave her more encouragement, cheers, and reminders of her progress and goals, (“Keep going!”, “You are doing so well!”, “We can see so much more of the baby’s head!”, “She has lots of hair!”, “Just a few pushes more”, “You are so strong, you are going to do this!”, “You can do this!”), she found the ability to keep going! Towards the end of the pushing stage Alyssa was (understandably) exhausted and was pushing in a modified lithotomy position while Jared and I supported both of her legs. Then all of a sudden Alyssa popped up and said (and I quote) “I need GRAVITY! I need to be UP!” as she sat upright into a full squat and pushed her baby’s head out with one gigantic roar! “Whoa, whoa!” the midwife and I said almost simultaneously, “Easy, easy, baby pushes.” “Blow like you are blowing out birthday candles,” I said. The midwife checked for a cord around the neck (which there was none) and cleared the baby’s mouth and nose. And with only a few more “baby pushes” Addison Joy was born at 2:27pm!

The room erupted into cheers of excitement and tears of happiness J! I put the baby skin to skin on mom as I dried her off with warm blankets and cleared her mouth and nose with the bulb suction. A quick palpation of the baby’s cord revealed that her heart rate was nice and strong and she was pinking right up! Jared and Alyssa kept hugging and kissing each other and talking to their new baby girl, “Hi Addison! Hi baby girl! I am so glad to finally meet you!” The midwife waited until the cord stopped pulsating before she cut it (per mom and dad’s birth plan) and checked Alyssa for any tears. Except for some swelling, she only had a small tear on her right labia that didn’t even require any stitches!! We kept mom and baby skin to skin for a full hour after birth and baby Addison nursed almost the whole time. When she was an hour old, I weighed her to satisfy mom’s curiosity and to everyone’s surprise the baby weighed 9 lbs 3 ozs!!! So much for “cephalopelvic disproportion” huh!!

And it was as I handed baby Addison back to Alyssa that she looked up at me and said softly, “I needed to know my body could do it. I knew my body could do it! I really needed this. Thank you.” So as you can imagine, I started to well up. I have never felt so honored to be a part of something so special. What a privilege to have a job where I witness the miracle of birth and the miracle of motherhood every week!

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So let’s recap shall we. Alyssa, after having a cesarean section for her 7 lb 5oz son two years earlier for “CPD” and “failure to descent”, pushed out a 9lb 3oz baby after a 6 hour and 27 minute labor, including 1 hour and 42 minute of mother-directed pushing, without any pain medications or an epidural, monitored by intermittent auscultation, needing not a single stitch to her perineum! Her tools included good and relevant labor & birth preparation, appropriate and helpful family support, sheer strength, determination, and will power. The midwife’s arsenal included extensive knowledge of and experience with natural birth and labor support, a doptone, a trust in birth, and a belief in Alyssa’s ability to do it! No medications, no vacuums, no scalpels, no scissors, and no doubt!

Boy how I love my job sometimes J

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*As always, names and any identifying information have been changed to protect privacy.

For more information on VBAC please visit: International Cesarean Awareness Network and Childbirth Connection