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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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/

 

An Interesting Encounter With A Medical Student May 8, 2009

Yesterday while I was at work, I had an interesting encounter with a medical student.  It was about 9:00pm and for me the shift was finally beginning to wind down.  I was taking care of a patient who was being induced for *post-dates* at 40 weeks and 1 day (don’t even get me STARTED on that!  Sheesh!) who had received a cervidil a few hours earlier.  I had just assisted her up to the bathroom and then tucked her in so she could try an get some rest.  As I came back to the desk, there was a medical student flipping through the book I had been reading called Silent Knife: Cesarean Prevention and Vaginal Birth after Cesarean (VBAC) by Nancy Wainer Cohen & Lois J. Estner.***   Typically the medical students do not spent much time talking to the nurses, at least in my hospital they don’t!  In my hospital, they generally can be found in the back lounge either sleeping or reading for class and they only pop out if a woman is about to deliver (they need to fulfil their quota after all ,so they can “pass” their OB rotation).  So for one to actually be sitting at the desk with me was a rarity, never mind actually talk to me!  (God forbid fraternizing with the enemy! Haha!  I kid!)  The following is our (brief) conversation:

 

Med Student:  “Is this your book?”

 

Me: “Yah.”

 

Med Student: “Do you have to read this book for work or school or are you reading it for fun?”

 

Me: (chuckling) “I’m reading it for fun.”

 

Med Student: (Holding my very reasonably sized book as if it weighed 500 pounds)  “I can’t believe you are reading this book for fun…It seems pretty intense.”

 

Me: “Well to be honest, I believe that the rising rate of unnecessary cesarean sections and the lack of VBAC opportunities for women in this country are pretty intense.”

 

Med Student: (quite perplexed yet in a “know-it-all” kind of tone)  “Well they are worried about a uterine rupture with a VBAC.  That means “vaginal birth after cesarean” right?”

 

Me:  (amused that she seems to be “schooling” me but doesn’t know what VBAC stands for)  “Who is the ‘they’ that you are referring to?”

 

Med Stuent:  “Well the medical community of course!”

 

Me:  (very calmly)  “The funny thing is my friend is that the research does not support this unnecessary, unfair “fear” of VBAC, especially for a spontaneous labor that is not being influenced by uterine stimulants such as misoprostol, cervidil, or pitocin.  RATHER decades of research have shown time and time again that the risks of unnecessary (especially repeat) cesarean surgery far outweigh the risks of a vaginal delivery, even if it is a VBAC.  It’s just that obsetricians in this country prefer to just cut people open instead of “wait around” for a vaginal delivery.  It’s quick and easy, for them anyway, not for the woman.  You see, with a cesarean, they can be home in time for dinner.  The only people that our skyrocketing cesarean rate is benefitting in this country are obstetricians.”

 

Med Student:  (completely and utterly dumbfounded)  “Well that is certainly not the impression they give you in medical school!”

 

At this point I could help myself, I laughed and laughed!  The med student was laughing too!  I told her that when I was finished with the book she could borrow it from me.  I don’t think she’ll take me up on the offer but at least I can take some comfort in knowing that I might have shaken her world up, even if just for one moment.

 

The moral of the story:  Any moment can be a teaching moment!

 

 

***Side Note: Silent Knife is an AMAZING BOOK and a MUST READ for anyone who had had a cesarean section or is being told she needs to have a cesarean section.  I am about 3/4 of the way through the book and I have a hard time putting it down.  It was written in the 1980s so some things are a bit dated but overall it is scary how little has changed for the better in our maternity care system in 25 years.  They might not be cutting as many episiotomies as they once were in this country but our skyrocketing cesarean rate and relatively poor maternal and fetal outcomes compared to other countries is makes this book as pertanent as ever!!

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Kristen writes:

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Why Is Vaginal Breech Birth Going the Way of the Dodo? April 9, 2009

I recently was sent a link to The Coalition for Breech Birth website and I wanted to share it with all of you because it is both interesting and informative.

 

I learned in nursing school and have since witnessed as an L&D nurse the hard truth that all breech babies are born by cesarean section in the United States nowadays unless 1) the baby turned from vertex to breech during the labor and no one realized it or 2) the baby actually delivered in the bed before her doctor could wheel her into the operating room.  I knew from books and stories told to me by older nurses that in the “old days” they used to deliver breeches vaginally but never learned why it isn’t even presented as an option for the women of today. 

 

According to the Coalition for Breech Birth website:

 

“Vaginal breech birth was practically banned following a significant international research study in 2000. This study, the “Term Breech Trial” or TBT, appeared to prove that caesarean section was substantially safer for the delivery of all breech babies. The trial was highly criticized, but many birth care providers took this opportunity to do what they wanted to do anyway – to stop offering vaginal breech birth to their clients, and to insist instead upon a surgical delivery.  In addition to all the professional criticism, the TBT’s own two year follow up negated the original results, suggesting that any difference in safety between vaginal and surgical birth of a breech baby is negligible – for both mother and child. Despite this evidence, many birth care providers (BCPs) still avoid balanced informed choice discussions with their clients, denying them the opportunity to make an informed choice.”

 

It is disappointing enough when a woman is not given the choice and is just scheduled for an elective pre-labor cesarean section (often at about 39 weeks, which could still be early for many babies) related to her baby being breech.   It’s also frustrating when a provider doesn’t even offer the patient an external version before scheduling her for surgery.   But what I find really upsetting as an L&D nurse is when a woman comes in 8, 9, or 10 centimeters dilated and because she is found breech is rushed of for an emergency cesarean section.  Many doctors say that one of the reasons they don’t “do” vaginal breech births is because the buttocks are not as effective at dilating the cervix as a nice round head is and labor can be too long and difficult.  But when a woman comes in at 10 centimeters dilated clearly her body did just fine!!  And when a woman “accidentally” delivers a breech baby in the bed before we could get her to surgery, everyone (doctors, nurses, midwives) seem to be so excited that the patient was able to “avoid” surgery, yet this hasn’t EVER made ANY doctor think twice about scheduling every one of their breech patients for surgery anyways.  So frustrating! 

 

If you have never seen a breech delivery before, this site has links to pictures and videos as well as other resources for mothers wanting to be more informed of their birth choices. 

 

The sad thing is that if things continue the way they are now, less and less doctors and midwives will be properly trained to assist in the delivery of a breech baby and by this vicious cycle, less and less opportunities for women to make this birth choice will exist. 

 

Don’t Let This Happen To You #25 PART 2 of 2: Sarah & John’s Unnecessary Induction April 8, 2009

Please see, Don’t Let This Happen To You #25 PART 1

 

After our conversation about her birth plan and induction, I focused my attention on providing Sarah & John with the support they needed to have a successful, empowering, and fulfilling labor and vaginal birth, despite the less than optimal circumstances. 

 

The first thing I did for Sarah was get her out of that bed!  At that time all of the portable telemetry monitors were in use by other patients (unfortunately we only have a few on the floor) so I couldn’t let her walk the halls.  But I explained that I could let her go as far as the cords would take her; basically she could sit in a rocking chair, stand at the bedside, and take “unlimited” trips to the bathroom for as long as she wanted (my own personal way of getting around the continuous monitoring.)  Sarah said she was most comfortable in the rocking chair since her back was bothering her in bed. (I bet!)  She reported at that time that the contractions mostly felt like “bad menstrual cramps.”  The next few hours I was in and out of the room since Sarah and John had things pretty much under control and I do believe that couples deserve privacy.  They were really cute together I have to admit.  While Sarah was rocking John was reading her poetry out of one of her favorite books.  It turned out to be the perfect amount of distraction for Sarah.  And Sarah did say to me that being in the rocking chair made her feel like she was actually “doing” something, as opposed to “just sitting in bed.”  Isn’t it interesting how just getting a mother out of bed can change her perspective for the better!

 

Over the next few hours I titrated the pitocin up or down depending on how frequent her contractions were coming, how Sarah told me she was feeling, and how strong the contractions felt when I palpated them.  Since we had talked extensively about her birth plan, I let Sarah know that Dr. F was planning on coming in around 2:00pm to check on her and break her water and that she had the right to refuse that procedure.  I explained to her that it was not an unreasonable request to ask him to wait.  I also told her that despite what Dr. F would probably say, it was NOT going to “slow down her labor” if she wanted to wait until she was more active, maybe even 7 or 8 centimeters, or just wait until her water broke on its own.   I also told her that I would support her decision and “stick up for her” with Dr. F, but that she was the one that had to tell him what she wanted first.  If not, it just makes the nurse look “pushy” and the doctor is less likely to abide.  

 

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

 

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

 

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

 

(Side note:  Dr. F is just plain wrong.  He, like so many mislead obstetricians, was utilizing his own anecdotal evidence instead of scientific research when he made his claim that amniotomy would “rev up” her labor.  A 2009 landmark study published by the Cochrane Database of Systematic Reviews concluded (after reviewing 14 studies involving 4893 women),“There was no evidence of any statistical difference in length of first stage of labour [between the amniotomy alone vs. intention to preserve the membranes group].  Amniotomy was associated with an increased risk of delivery by caesarean section.  On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care.”  This study hangs in the doctor’s lounge at my hospital and I have actually shown it to quite a few physicians who believe in early and routine amniotomy.  And they ignore it and do what they want anyways.  It’s infuriating!  It’s like they only care about research that supports what they already do and if it goes against their practice, they pretend it doesn’t exist!)

 

Sarah: “I’d really rather wait.”

 

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

 

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

 

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

 

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

 

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

 

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

 

Me: “No, I have her at 10mu/min.”

 

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

 

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

 

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

 

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

 

Dr. F:  “I was being generous!”

 

Me: “So you lied…”

 

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

 

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

 

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

 

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

 

So since I had her blessing, I kept the pitocin at 10mu/min.  By this point about a half an hour had passed and I went to go check on Sarah in her room.  When I entered I noticed that Sarah was breathing pretty hard during contractions and John was no longer reading poetry.  In fact, John looked like a deer in headlights.  “The contractions feel so much stronger since the doctor examined me!” said Sarah.  “That’s great!” I said reassuringly.  “I think I want my epidural now,” she said as she breathed through a contraction.  “Where are you feeling the pain the most?” I asked.  “In my back, my back is killing me!” she said. 

 

Let me digress for a moment to explain my three rules regarding epidurals: 

 

#1  You can’t ask for an epidural during a contraction.

#2  If you say “I think I want,” we need to try something else first.

#3  You can’t ask for an epidural if you are lying or sitting in bed.

 

If one of the three circumstances above is present, I have two techniques that I employ:

 

#1 The 3 Contraction Technique:  You have to try at least one position change for three contractions first and then we reevaluate how you feel.

 

 

#2 The 15 Minute Technique: You have to try at least one position change for 15 minutes first and then we reevaluate how you feel.

 

Since Sarah said “I think I want” it was important to try something new first J.  I always explain to my patients that epidurals pose higher risk of cesarean section the sooner they are given in labor and I did reiterate this to Sarah.  In my opinion epidurals and pain medication should only be a last resort when everything else in my bag of “nonpharmacological comfort” tricks has been tried.  She agreed to the “15 Minute Technique” so I (finally) obtained and attached her to a portable monitor, got her on her feet, showed her how to drape her arms over John’s neck as if they were slow dancing, and the showed her how to sway/squat during a contraction.  While Sarah and John were “dancing” I was rubbing lavender Bath and Body Works lotion on her back and applying counter pressure to her sacrum to relieve her back pain during a contraction.  And guess what…Sarah slow danced for TWO HOURS!  She had definitely drifted off to Laborland, where time does not exist and you take life one contraction at a time J.

 

“I’m starting to feel more pressure in my bottom like I have to poop,” she said.  What a great sign!  I explained to Sarah that eventually that pressure would not only be felt during contractions but between them as well.  Sarah was getting tired so we tried some kneeling on the bed for about a half an hour while John rubbed her back.  Around 5:00pm Dr. F sauntered on in to check Sarah and as he had said he would earlier.  All that hard work certainly paid off, Sarah was 6-7 centimeters dilated!!  “I need an epidural now!” Sarah assertively told Dr. F.  “Okay sure!  I’ll write the order.  But first I am going to break your water,” he replied.  So I took a deep breath and with my best impression of an adorable puppy dog I cheerfully asked, “Could we please wait until she has the epidural in place first before you rupture her Dr. F?  That way she won’t be leaking all over herself as she is hunched over for the epidural?”  (Sometimes you gotta do what you gotta do!)  Surprisingly he agreed and after he left the room I helped Sarah to the bathroom to pee. 

 

However, it turned out that at that time, another patient was in the operating room for a cesarean section and there were two other patients “in line” for epidurals before my patient was.  And since we only have one anesthesiologist in house and no others were available to come in, Sarah would have to wait.  I explained all of this to her and showered her with support and encouragement regarding how far she had come, how much work she had done, and how she could make it any amount of time longer until she got her epidural because she was a strong woman!  I don’t know how much of it she bought at that point in time because she was really really uncomfortable but regardless I couldn’t get her an epidural “now” so she would have to wait anyhow!

 

The next two hours or so (yup, the cesarean ran long and with two other epidurals in line, it took anesthesia two hours to get to Sarah) were spent walking around the room, hands and knees, side lying, kneeling, hunching over the counter, etc etc etc.  By this point Sarah was almost at her breaking point so I offered up one final suggestion: Let’s sit on the toilet.  Although skeptical at first, Sarah finally agreed to give it a chance and for the last 20 minutes before anesthesia arrived Sarah sat on the toilet, rocking back and forth.  (Turns out skeptical Sarah actually liked sitting on the toilet.  I asked for her to just give it “three contractions” and then we could get back to bed.  After three contractions she asked if she could just stay there until anesthesia came!  Hmmm, maybe this L&D nurse actually does know a thing or two J

 

By this point it was 7:00 pm.  The anesthesiologist had to poke Sarah twice to get the epidural in the right place, (Which happens a lot!  That’s another risk!  They are working blind after all!) and so we were not completely done with the epidural until 7:45-8:00pm.  I propped Sarah up on her side with a bunch of pillows, put the baby back on the monitor, shut off all the light and tucked her in.  She was snoring before I could leave the room.  At least she can take a little nap before she has to push, I thought to myself.  But what do you know, about 15 minutes later Dr. F came barreling down the hall.  I saw him coming so I jumped from the desk and said “Are you going into room 11? She just JUST feel asleep.  Please can we let her sleep for a bit?!”  No luck.  “What?!  No, I HAVE to break her water.  This is getting ridiculous now, its 8:00 for goodness sake!” he barked.  So I hung my head like Charlie Brown and followed him into the room.  He flipped on all the lights (is that really necessary) and Sarah sprung up from her sleep.  The good news however was that Sarah was 8 centimeters!!  I reluctantly passed the amniohook to Dr. F and he ruptured Sarah’s membranes.  Clear fluid…good!  I took the opportunity to change all the bedpads under Sarah and turn her to her other side.  “I’ll be back in a hour to check you again”, said Dr. F as he brushed out of the room.  I encouraged Sarah to take the next hour to try to rest as much as possible (no TV or talking on the cell phone!!) and went back out to the desk. 

 

As 9:00pm approached, I started to get a pit in my stomach.  I had a gut feeling that Sarah was probably going to be fully dilated when Dr. F came back and I was worried that because he wanted to get home (Sarah was his only patient on the floor) he would rush her into pushing before she could feel her bottom and we would end up with a cesarean section for “failure to descent.”  So at 10 minutes to 9:00pm I took a chance, went into Sarah’s room, and said the following:

 

“I remember reading in your birth plan that even if you are fully dilated you would like to wait until you feel the urge to push before you start the pushing phase.  Is this still true?  (Both Sarah and John answered yes.)  Okay, how are you feeling right now?  Do you feel the urge to push when you have contractions?  (Sarah told me that she couldn’t feel much of anything and did not have the urge to push).  Okay, so basically what I am trying to say is that I think it is a totally reasonable request to want to wait until you can feel the urge to push.  So when Dr. F comes to check you, if you are fully dilated it is okay to ask him to shut off the epidural and give you some time to start to feel the urge to push.  You don’t have to start pushing right away.  In fact, if you do, you will probably push for WAY longer than you have too.  I will back you up.   I know it sounds scary to shut off the epidural but trust me, pushing isn’t going to be so scary because you can actually DO something about all these contractions and pushing when you can feel the urge is a lot easier.”

 

Both Sarah and John agreed.  I had said my peace and turned to leave the room but at that time in came Dr. F.  He checked her and what do ya know, she was fully dilated!!!  (But still at a zero station).  “Okay, let’s start pushing!” he said as he pulled over the delivery table.  “Umm, I don’t really feel anything yet so can I wait until I can before we start?”  My whole face lit up with excitement; I was SO proud of Sarah for advocating for her birth plan!  So then I chimed in, “It’s part of her birth plan, Dr. F, can we shut off the epidural and give her at least an hour before you check her again?”  “Well let’s see how she does first,” he said annoyed, and asked Sarah to give him a “practice push.”  Thankfully this convinced him that she certainly could not feel her bottom and he agreed to come back in an hour.

 

The best part was that after Dr. F left the room John turned to me and said “Wow, did you call that one or what!”  I have to say it made me feel better that someone noticed how predictable doctors can be J

 

I shut off the epidural and for the next hour sat with Sarah and John and coached them through transition.  Although nauseous Sarah never threw up, but the pressure in her rectum was certainly getting more intense for her.  We worked on breathing for about 30-40 minutes and the last 20 minutes I showed her how to grunt during contractions and do little baby pushes to relieve some of the pressure she was feeling.  And then she said the magic words “I think the baby is coming!”  Those words ring like a choir of angels to my ears!  As I was leaning towards the call bell to page Dr. F into the room, the door opened and it was him.  He checked her and with a look of surprise said “Wow! You are a plus 2 station now!  You have done a lot of work in here!!”  I was smiling so big I thought my cheeks were going to explode! 

 

Sarah felt more comfortable pushing on her left side so John supported her right let while I supported her neck, applied cold washcloths to her forehead, and offered sips of cold water. 

 

At 10:45pm after only 37 minutes of pushing, Sarah (a first time momma) gave birth vaginally to Elizabeth Joy, weighing in at 9lbs 1 oz!!  She had a second degree perineal tear that required only a couple small stitches and never required an episiotomy, forceps, or vacuum extractor.  Sarah spent the first hour skin to skin with Elizabeth and got a great start with breastfeeding.  I only wished that I didn’t have to leave at 11:30pm and could have gotten to spend the whole 2 hour recovery time with them.  I left the hospital that night exhausted but empowered, drained but excited, and so incredibly proud of Sarah and John for sticking to their convictions and advocating for their birth experience.  I must have said to her a million times through my tears of joy, “You did it!  You did it!  You did it!” 

 

It is such a shame that it takes so much energy to fight for your right to your own birth experience during a hospital birth.  I think the mix between Sarah, John, & I was a great one, yet it still took a lot of effort on everyone’s part to avert unnecessary interventions and protect their birth plan.  And unfortunately, it was all made much more difficult starting from the very beginning when Sarah was scheduled for an UNNECESSARY LABOR INDUCTIION.  I thank God that Sarah ended up with a rewarding and empowering vaginal birth but things could have taken a turn towards CesareanTown at any point along the way, NOT related to natural labor, but related to INTERVENTIONS. 

 

The morals to the story are this:

 

1)     Remember LABOR & BIRTH are natural, INTERVENTIONS are risky, NOT the other way around.

2)     Even if you are planning on an epidural, uncontrollable circumstances may require you to labor without one for longer than you thought and therefore labor and birth preparation, whether it be reading books, taking a class, hiring a doula, or talking with other moms, is just as important if you are planning for an epidural as if you were planning for a natural birth.

3)     If you have had a healthy, uneventful, normal pregnancy up until your 37th week and your baby has a reactive non-stress test it is important to seriously question your doctor or midwife if they are suggesting, offering, or pushing a labor induction for you.    

 

Don’t Let This Happen To You #25 PART 1 of 2: Sarah & John’s Unnecessary Induction April 5, 2009

Introduction to 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!” 

 

What do I mean?  If you have ever watched the amazing documentary The Business of Being Born and thought to yourself, “Oh no, that can’t be true?  That must be an exaggeration,” I am here to tell you that it is NOT an exaggeration. 

 

The fact is, the current state of maternity care in the United States is in a crisis and many times I find myself feeling defeated and helpless regarding it all.  I mean don’t get me wrong, I take my job as a nurse and patient advocate very seriously and protecting the health, safety, and autonomy of my patients is very important to me.  So seriously in fact that I have all but thrown a screaming fit at times when faced with particularly outrageous obstetricians and unjust circumstances.  (Oh wait, I have thrown screaming fits before…Haha! J )  In the end I often find myself working with nurses that I feel are dedicated and fantastic, but who none the less have had to put up with this bullshit for so long that they sort of become complacent to it. 

 

So where does that leave me?  I feel my position as an L&D nurse really puts me at the end of the line when it comes to affecting change in how woman and families approach pregnancy and childbirth.  One of the things that really inspired me to start this blog was that I realized I really only get my “hands” on families after they have already been sucked in to the medical model of maternity care.  One particularly hard pill for me to swallow is this country’s epidemic of women undergoing unnecessary interventions, including but not limited to, the inappropriate use of labor induction and augmentation and unnecessary primary and repeat cesarean sections.  But the more and more I have worked in this “culture” and talked with these women and families, the more and more I have realized that all too often these women are really lured in and duped into these interventions!  That true informed consent is not really obtained and alternatives to the obstetrician’s (and even some “med-wives’ ”) proposed course of action are NOT provided.  And a few days ago I took care of a patient that was really just the straw that broke the camel’s back. 

 

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!  Since I prefer countdowns instead of count ups, I decided to start at a random number.  I have no doubt I will be able to come up with 25 situations I have found myself or my patients in that could easily make the list.  (Hmmm, maybe I should start at 1000! J )

 

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Don’t Let This Happen To You #25: PART 1 of 2

Sarah & John’s Unnecessary Induction for “Oligohydramnios” and “Post-dates”

 

I came to work for 11:00 am as usual one cold and rainy Monday morning and despite the many obvious reasons to be in a bad mood, I was actually pleasantly optimistic about my upcoming shift.  Things seemed to be going my way when I saw my assignment.  I would be taking over a laboring patient of Dr. F’s in room 11 for a nurse who was only working a half shift.  Since assisting women during labor is my favorite part of being an L&D nurse, I was happy.

 

So I went to the desk closest to the patient’s room and started to look over her chart until her current nurse was ready to give me report.  Let’s see here…26 year old first time mom, first pregnancy (G1P0), no medical risks in her health history, no complications during this pregnancy.  According to her LMP she is 40 weeks and 5 days (“aka” still 9 days away from 42 weeks or true “postdates”).  A quick look at her most recent ultrasound report (performed 3 days earlier) showed a Grade II placenta (“aka” normal, healthy and well functioning), an amniotic fluid index (AFI) of 8.4 (“aka” normal, since at term a normal AFI is anywhere from 5-25), and an estimated fetal weight (EFW) of approximately 3628 grams (or 8 lbs 3oz). (Note: It is well documented in the medical literature that third trimester ultrasound scans can be off by as much as +/-2 pounds when estimating fetal weight!).  Looking at the fetal heart rate pattern on the computer showed a reactive and reassuring strip with moderate variability, presence of great accelerations and absence of decelerations.  Her vaginal exam on admission was 3cm, 70% effaced, minus 2 station.  Hmm…she must have been admitted for labor….oh wait…what’s this in the doctor’s admission note?….

 

Indication for admission: Induction for oligohydramnios (low amniotic fluid) and post dates.

Plan: pitocin and early amniotomy.

 

WHAAAAAAAAAAAAAAAAAAAAAAAT?!?!

 

A double, triple, quadruple take proved to me that my eyes were not failing me.  And to top it all off the patient had provided us with her birth plan.  Now I don’t mean that to be sarcastic because I am not against birth plans.  It’s that her birth plan was basically requesting things that because she was being induced with pitocin, were prohibited, discouraged, or generally made very difficult by our hospital’s policy and her physician’s orders/philosophy. 

 

Here is an excerpt from her birth plan.  Although I don’t have a copy of her actual birth plan, since almost every pregnant woman with a birth plan seems to find the same website (www.birthplan.com), I can confidently replicate it quite easily.  My responses to why each of these reasonable requests were prohibited, discouraged, or generally made very difficult are provided in italics after each bullet:

 

§        I would like to be free to walk around during labor. (Although walking is not contraindicated during an induction, since the use of pitocin requires the use of continuous external fetal monitoring (EFM) and a good tracing of the fetal heart rate (FHR) and contractions, a portable telemetry monitor must be used.  And since it is a machine with limitations, as the baby swish, swish, swishes in her amniotic fluid womb bath, more often than not adequately tracing the fetal heart rate is impossible or extremely difficult, especially if the woman has a lot of extra “cushion”.)

§        I wish to be able to move around and change position at will throughout labor. (Tracing the FHR with continuous EFM is virtually impossible sitting on a birthing ball or leaning forward, positions that many women find comforting, unless you hold the monitor constantly with your hands, something that is very difficult for even the most well intentioned nurse, especially if she has more than one patient.  It is also often annoying for the patient.)

§        I do not want an IV unless I become dehydrated.  (Since pitocin is a medication administered via an IV infusion, it necessitates an IV.)

§        I do not wish to have continuous fetal monitoring unless it is required by the condition of the baby. (Induction with pitocin requires continuous EFM, even in the most lenient of hospital policies.)

§        I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring.  (Was the doctor’s plan even discussed with this patient?!)

§        I would prefer to be allowed to try changing position and other natural methods (walking, nipple stimulation) before pitocin is administered.  (Ummm…hello!)

§        Unless absolutely necessary, I would like to avoid a Cesarean.  (One of the best ways to avoid an unnecessary cesarean is to avoid an unnecessary labor induction!!  See #8 in my post: Top 8 Ways to Have an Unnecessary Cesarean Section)

§        Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.  (We’ll get to this one later.)

 

So then came the nurse I was supposed to get report from.  “Umm, why the hell is she being induced?!,” I said.  “Oh brother, I know.  Its bullshit isn’t it!  We started the pit this morning at 8am but Dr. F couldn’t rupture her membranes at that time because the baby’s head was still high.  He said he’d be back around 1:00 pm to do it.” she replied.  “Like hell he will,” I thought to myself.  And after a quick report I entered Sarah’s room to try to get some answers. 

 

Upon entering the room Sarah was sitting up comfortably in bed while her husband, John, was typing on his laptop in a chair beside her.  First I introduced myself and let them know that barring an emergency, I would be their nurse for the next 12 hours and probably for the birth of their baby!  We engaged in some small talk for a bit, the typical “Where’re you from?  What do you do?  What’s the baby’s name going to be?”  “How has this pregnancy been for you? yaddy yaddy yada.  We then talked about their birth preparation.  Turns out they had taken a childbirth preparation class and had read two of my favorite books: Ina May’s Guide to Childbirth and The Birth Partner.  Good start!  Next I pulled up a stool and with their birth plan in hand, went over all of their plans with the both of them before things started to rev up for Sarah. 

 

Whenever a couple has a birth plan, whether it be a birth plan for as natural a birth as possible, as medicated a birth as possible, or anything in between, I like to actually sit down and review each point with them to let them know what is totally doable or what must be modified related to the patient’s condition or hospital policy.  I let them know that my main jobs as a nurse are to provide support, assure the safety of the mother and baby, and be a patient advocate.  That way everyone is on the same page and I think it helps build some trust between couple and nurse.  Kind of like saying “Hey, I am going to take your birth plan seriously since this is your experience, but we might have to compromise on some things.” 

So I started to go over the couple’s birth plan with them and basically tell them how induction with pitocin makes many of their requests impossible or very difficult but that I would do the best I could under the circumstances.  And this is where things got interesting.  The following is our conversation:

 

Sarah: “Oh yeah, I know.  We had this big birth plan for a natural birth but that’s okay, I mean, when Dr. F told us two days ago that we needed to be induced, I realized that we couldn’t have everything we had planed for.”

 

Me:  “Oh, what did he tell you was the reason you had to be induced today?” 

 

Sarah: “Because the baby’s amniotic fluid was too low and I was overdue.” 

 

John: “Yeah, umm, about that…  Two days ago was the only appointment I had missed and it’s when they set her up for an induction.  I didn’t even get a chance to ask the doctor what the normal levels for AFI were.  I mean, he told us our level was 8.  What is normal?” 

 

Me: “5 to 25 is normal for a term baby,” (stated matter-of-factly)

 

John: “SEE!  Then 8 is totally fine!  And technically we still have a week left before we are considered really ‘overdue’, right?”

 

Sarah: “John, really, relax.  It’s no big deal (awkward laugh).  We’ll know better for next time.  Really, it’s okay.  Let’s not cause any trouble.”

 

John: “Melissa, what are some really important reasons for induction.  Like, what are some real medical reasons where induction is necessary?”

 

Melissa: “Umm, do you truly want me to go into this?  Because I can but…”

 

John: “Yes please.”

 

Melissa: “Well to name a few off the top of my head:  If the baby is showing serious signs of distress on a non-stress test and biophysical profile, an AFI consistently less than 5 over multiple readings, worsening preeclampsia, signs of intrauterine growth restriction, a placenta that shows signs that it is getting too old too early in the pregnancy, etc.”  (This is where things started to get awkward for me.  I mean, I didn’t want to upset Sarah or make her feel self-conscious or distrustful of her physician because those feelings are certainly NOT going to facilitate a smooth labor.  But then again, I secretly wanted to tell her, “You don’t have to be here!”)

 

John:  “Well, the baby has had a great non-stress test every time we went to the doctor and he told us the placenta is healthy, and Sarah is healthy and her pregnancy has gone off without a hitch, she didn’t even really get morning sickness, and they said the baby is probably 8 lbs, which certainly isn’t too small!  This is really frustrating!!”

 

Sarah:  “John, it is okay.  Dr. F must have thought it was important that I deliver.  So we’ll just know better for next time.  Next time we’ll be more prepared.  But we’re here now and I am already being induced.”

 

I could see that there certainly was some tension between them regarding this issue and it seemed to me that although Sarah agreed with what John was saying, she was worried about causing any conflict or confrontation between her and Dr. F.  But I have to admit that it really bothered me that she kept repeating “We’ll know better for next time,” because THIS time is important and THIS time could have negative affects on NEXT time. 

 

Situations like this are one of the things that frustrate me the most about my job.  Sarah and John were both intelligent people.  (The were high school teachers with master’s degrees for goodness sake!).  They read the right books.  They attended childbirth classes.  They wrote a birth plan and showed it to their obstetrician earlier in the pregnancy.  (Of course I can almost guarantee that he briefly looked at it, gave them a blanket “okay” but didn’t really take the time to go over it piece by piece with them.)  And yet they were still duped into an unnecessary induction.  It is such a shame that there are so many women I care for that are more afraid of being considered a “difficult patient” for sticking up for themselves than the risks of unnecessary intervention.  It’s like being afraid to tell your hair dresser you don’t like the hair cut she gave you TIMES A MILLION!  In my opinion they were NOT provided with informed consent and NOT given the opportunity to give informed refusal.  And in my opinion once they were told they “needed” to be induced, they felt trapped and didn’t want to “cause any trouble” with the doctor. 

 

To be continued….

 

Up For Next Time: Don’t Let This Happen To You #25: PART 2 of 2 

 

Read about Sarah’s labor, the birth of her baby, and how all three of us had to fight to fulfill her birth plan!