Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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

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

 

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

 

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

 

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Hi NursingBirth!

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

  

Sincerely,

Jessica

  

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

 

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

 

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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.

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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.

 

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(Patient signature/legal representative)                        

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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:

 

 

 

 

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***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.

 

 

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. 

 

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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. 

 

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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.

 

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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.

 

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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

 

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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:

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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…

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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* 

 

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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)