Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

“Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions July 9, 2009

Yesterday in my post entitled “Pit to Distress: A Disturbing Reality” I wrote about a troubling way of administering the drug pitocin to augment or induce labor that some birth attendants are practicing in our country’s maternity wards.  Called “pit to distress”, the intention is to order a nurse (either verbal or written) to continue to turn up (or “crank” as is the current L&D slang) the pitocin in order to induce hyperstimulation/tachysystole of the uterus so that a women is experiencing more than 5 contractions in a 10 minute period.  This action, sooner or later, will cause fetal distress as research has shown that a baby needs AT LEAST a 1 minute break in between contractions where the uterus is AT REST in order for the baby to continue to receive adequate oxygenated blood flow from the placenta and not have to dip into his reserve. 

 

Inspiration for my post came from two posts on the subject written by Keyboard Revolutionary and The Unnecesarean.  Since yesterday I have received many comments regarding this upsetting trend and one comment in particular has inspired me to address the topic again:

 

 

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July 8, 2009

 

Dear NursingBirth,

 

I really enjoy your blog and I learn a lot from all your posts. I am wondering if there is a way (as the patient) to know if something like this is happening and refuse it? Is the patient always told how much pitocin she is getting and can she say at a certain point that she doesn’t want it any higher if she is making progress?

 

Sincerely,

Zoey

 

 

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Dear Zoey,

 

This is a GREAT question.  I love hearing from women who desire to learn more about their choices in childbirth and become more proactive in the care they are receiving.  KUDOS to you for doing both!!  I have thought a lot about this and I have come up with a list that I hope you find helpful.  Please pass it along to all of your friends, both expecting and not, so that we can both work to inspire more women to do as you do….that is, DO their research and DEMAND better care!!!

 

 

 

TOP 7 WAYS TO PROTECT YOURSELF FROM UNNECESSARY AND HARMFUL OBSTETRICAL INTERVENTIONS (including “Pit to Distress”!)

 

 

#1  Interview different birth attendants/practices before or during early pregnancy and CHOOSE a birth attendant that practices in a way that aligns with your personal childbirth/postpartum philosophy, is appropriate for your health status, and (optimally) who practices a midwifery model of care!

 

I wish I could scream this from the roof tops!  Sometimes I feel like a broken record I say this so often but I say it so often because it is SO important!!  The bottom line here ladies is that if you think you can pick any care provider you want and then just write a birth plan that clearly states your philosophy and preferences and just get what you want…..THINK AGAIN!  Birth attendants are creatures of HABIT more than anything else.  If they cut an episiotomy on the majority of their patients then what makes you think that if you ask, they won’t cut one on you?  In fact, not only will they cut one on you but they will come up with some bogus reason why it was necessary.  Likewise, if your birth attendant induces most of their patients, what makes you think that he won’t start pressuring you to set up an induction date once you hit 37 weeks! 

 

Think of it this way, if the birth attendant has a high elective induction rate, they probably feel more comfortable managing pitocin induced or augmented labors as opposed to spontaneous labors and hence, they will probably try to do everything in their power [including persuasion (e.g. the “convenience” card and the “aren’t you sick of being pregnant” card) as well as scare tactics (e.g. the “big baby” card, the “I might not be there to deliver you if you don’t” card, or my favorite the “if you don’t your baby might be stillborn/dead baby” card)] to convince you that your labor needs to be induced or augmented with pitocin.  Why?  It probably is a mix between how they were taught (i.e. medical model of maternity care), what they are used to (a self fulfilling prophecy), and a desire to be the one in “control.” 

 

Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:

 

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

 

So PLEASE for the LOVE of all mothers and babies, PLEASE do your homework! 

 

Of course there is always the chance that you do interview a particular birth attendant and they act one way in the office with you and then, WHAM!, are a completely different person when you step foot on L&D.  I see it happen ALL THE TIME where I work.  Just because a doctor gives you his home phone number and is sweeter than sugar in the office, doesn’t mean he won’t section you just to get to the company Christmas party!  (This actually happened to a patient I took care of!  NO lie!)  So what can you do about that! 

 

Jill from Keyboard Revolutionary recently blogged about this:

 

“Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We’ve all shaken our fists in righteous indignation at the rants of Marsden Wagner. We’ve listened intently to the poetic, thickly accented declarations of Michel Odent. We’ve swooned over the tender ministrations of “Dr. Wonderful,” a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.

 

I was pondering just now in the shower how so many of us think we’ve got a real gem of an OB (or any other doctor, really) until show time, and suddenly we’re hit with the ol’ bait-and-switch. Sometimes there are warning flags along the way, sometimes not. Sometimes the flags don’t pop up until it’s too late. It sucks that for many women, we don’t realize what a crock we’ve been fed until we’ve already digested it. How do you know whether you’ve got a bad egg or your own Dr. Wonderful?”

 

This leads me to my second point…

 

 

#2  Ask the RIGHT QUESTIONS and the RIGHT PEOPLE when researching potential birth attendants.

 

Two of my favorite posts from Nicole at It’s Your Birth Right! are her posts about choosing the right birth attendant entitled Choose Wisely I and Choose Wisely II.  She writes:

 

“The decision about WHO is going to be your birth attendant should NOT be left to chance.  Where you deliver, how you choose to labor, what you chose to do while pregnant and in labor, while these things are definitely important, without the proper WHO, the plan will have difficulty coming together.

 

I get questions, all the time from friends, friends of friends and even strangers.  They want my thoughts about pregnancy, labor and childbirth. I have spent HOURS talking with women providing answers and information they should be able to get from their prenatal provider/birth attendant.  I think to myself at the end of those conversations, “Why isn’t she able to get this information from her?  If  he doesn’t make her feel special, does not answer her questions, and doesn’t agree with her philosophy on childbirth and labor, why on earth is she allowing him to be her birth attendant?!”

 

When I pose this question to the women themselves, the answers unfortunately never include “Because I did my research and I found him to be the best match for me and my desired childbirth experience.”  Most of the answers I receive fall into [one of] four categories, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant.   They are: “She delivered my sister/girlfriend”, “She is my gynecologist,” “He is the best/most popular person in area,” and “Her office is so close and convenient to my office/house.”

 

Now I am not trying to say that you shouldn’t trust your sister, sister-in-law, or best friend’s opinion about her personal birth attendant but if you are going to ask such a person for advice please remember that she probably has only had limited experience with that birth attendant as compared to, say, an L&D nurse or doula, and it is important to ask her exactly why she loves her birth attendant so much.  Does she love him because he trusts in birth and strived to facilitate a positive and empowering birth experience for her or does she love him because he was the only OB in the area that would agree to induce her at 38 weeks because she was sick of being pregnant?  There is a difference!!

 

If you have done some research and found a birth attendant that you think you really like, I would recommend tapping into some community resources to get the “inside scoop” about your birth attendant.  Here are some ideas:

 

1)      Contact your local grassroots birth advocacy group like International Cesarean Awareness Network (ICAN) or BirthNetwork National and try to attend a meeting.  The women that attend these meetings are often in tune with the birth culture in their community and can be GREAT resources for which birth attendants are true and which are really wolves in sheep’s clothing!  Also, don’t count out ICAN as a resource even if you have never had a cesarean.  We have a quite a few moms currently in my local ICAN group that are first timers and decided to start attending because they said they were learning so much about birth in general from our meetings!

 

2) Sign up for a childbirth preparation class that is NOT funded/run by a hospital and ask the instructor for her opinion on different birth attendants.  It is the only way to guarantee that your instructor is not held back from speaking her true feelings since hospital based childbirth instructors are working for the interest and promotion of their hospital by the very nature of their job.  Independent childbirth instructors like Lamaze, Hypnobabies, Birthing From Within, Bradley etc. etc. can be GREAT resources as to which birth attendants follow which philosophies because often times their clients come back and tell them about their experiences.

 

2)      Consider consulting or hiring a doula.  A doula is a great resource as to the true nature of a birth attendant because she is someone who is actually in the labor and delivery room with her clients and has as close to an “insider’s view” as you can get without actually working for the hospital.  If you hire a doula to be with you during your labor, they will also advocate for you, your needs, and your birth plan as well as provide essential labor support that (unfortunately) even the most well intentioned nurse might not have the time to do. 

 

 

#3  Do NOT agree to an induction of labor unless there is a legitimate obstetrical, maternal, or fetal reason for delivering the baby before natural spontaneous labor begins!!  PLEASE Do NOT agree to an unnecessary elective induction of labor. 

 

This might seem like a no brainier ladies but so many get sucked in!  They don’t call it “the seduction of induction” for nothing! 

 

Bottom line is if you want to protect yourself from such an asinine, unnecessary, and dangerous intervention as “Pit to Distress” then DON’T agree to be induced unless there is a very important medical reason!

 

BABIES AND MOTHERS HAVE THE BEST OUTCOMES WHEN THEY ARE ALLOWED TO BEGIN LABOR SPONTANEOUSLY AS WELL AS LABOR AND DELIVER WITH MINIMAL INTERVENTIONS!

 

In the Lamaze Institute for Normal Birth’s MUST READ patient education bulletin entitled Care Practice #1: Labor Begins on Its Own, author Debby Amis, RN, BSN,CD(DONA), LCCE, FACCE, and editor Amy M. Romano, MSN, CNM write:

 

“There is growing evidence that induction of labor is not risk-free. In 2007, Goer, Leslie, and Romano reviewed the entire body of literature on the risks of induction in healthy women with normal pregnancies and found that when labor was induced, the following problems may be more common:

  • vacuum or forceps-assisted vaginal birth;
  • cesarean surgery;
  • problems during labor such as fever, fetal heart rate changes, and shoulder dystocia;
  • babies born with low birth weight;
  • admission to the NICU;
  • jaundice;
  • increased length of hospital stay.”

 

Okay, enough said!

 

 

#4  If you have to be induced or augmented with pitocin for a true medical or obstetrical reason, be honest with your nurse about how you are feeling and have one of your labor companions keep track of how often your contractions are coming.

 

And this does NOT mean for your labor companion to “monitor watch”!!  It’s not a TV for goodness’ sake!

 

Research has shown that due to the risks of pitocin, continuous electronic fetal monitoring (CEFM) is a safety requirement for anyone being induced or augmented with it.  However, remember CEFM is a machine and machines have limitations.  The tocodynamometer or “toco” is “pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper.”  However, depending on your body type, how “fluffy” your abdomen is, your position, and your gestational age, the toco might not be recording your contractions appropriately.  You might be having contractions every minute but the machine is not registering them.  This is why I always remind women that they have to tell me how they are feeling. 

 

If you are being augmented or induced with pitocin your nurse SHOULD:

 

1)      Be palpating (feeling) your fundus (top of your uterus above the belly button) before, during, and after contractions periodically throughout your labor to judge how strong they are (mild, moderate, or strong).  Palpation before and after contractions also assures the nurse that your uterus is actually coming to rest (is soft) between contractions, which assures that the baby (and mom!) are getting a break!  Remember, unless you have an IUPC (intrauterine pressure catheter) in, the toco can only tell the nurse how far apart and how long the contractions are NOT how strong they are!  That’s right!  Unless you have an IUPC in, the height of the contractions on the monitors is ABSOLUTELY MEANINGLESS!  So therefore the only way for the nurse to know how strong the contractions are is to TOUCH your belly and ASK you!

 

2) Ask you about your pain level (for example to “rate” your pain on a scale of 0 to 5 or 0 to 10) regularly during your labor unless you have specifically asked her not to ask you about your pain.

 

3) Give you periodic updates on your progress and the progress of the pitocin.

 

[Note: I can only speak for myself here but what I do when I have a patient on pitocin is first and foremost to explain the process of titrating the pitocin and what the desired outcome is (and according to our hospital’s policy the desired outcome is moderate to strong contractions that are coming every 2-3 minutes, or 3-5 in a 10 minute period), as well as keep her informed throughout the process when I am increasing or decreasing the pitocin and for what reason.  For example, I might say “It looks to me like you are contracting every 4 minutes.  What is your pain level?  Do you feel like you are getting an adequate break?  Would you like to change position?  I would like to increase to pitocin to achieve a more regular pattern.  What do you think?” or “It looks like the baby continues to have variable decelerations in his heart rate despite all of the position changes we have tried.  I am going to give you a small IV fluid bolus and turn the pitocin down some to see if it helps to resolve the decels.  The baby’s variability is still very reassuring and she is still having accelerations so she is doing well.  I just would like to keep her that way!”  Your nurse should be keeping you “in the loop” so to speak and if she is not, it is your right to ask questions!]

 

It is also important to remember that that running pitocin is much more of an art than a science.  Therefore you might think she is being “mean” if she is increasing your pitocin since you are only contracting every 6 minutes but remember, running the pitocin lower than is needed to cause cervical change isn’t going to help you either.  No nurse wants her patient to end up in the OR for “failure to progress” because she didn’t turn the pitocin up enough.  There is a happy medium somewhere that most nurses are trying to find.  So please, know that sometimes, even if you really feel like those “every 6 minute” contractions are strong enough already, it is important for the nurse to titrate the medication to achieve an effective labor pattern that promotes a vaginal delivery with a healthy baby. 

 

If your nurse is NOT doing these things then it is your right to ask questions!!!  However, please remember for your own sake that when asking questions, one attracts more flies with honey than vinegar.  Don’t start yelling at her or demanding a new nurse.  Give her a chance and ask questions first!  She might just be so busy that day that she is in the zone.  Most nurses are happy to teach when asked!

 

 

#5  Learn about and practice non-pharmacological methods of pain relief as part of your childbirth preparation and consider not getting or postponing an epidural until all other methods of non-pharmacological pain relief have been exhausted. 

 

Okay, I know that this one is a bit controversial but please here me out first. 

 

It is the truth that pitocin contractions, especially when the pitocin is being abused, are typically stronger and longer than spontaneous labor contractions.  Also, being that you have to be on continuous monitoring can also limit your movement and hence, one of your most effective and instinctual coping methods for the pain.  For this reason, many people feel that it is crazy for a woman to go though a pitocin labor without an epidural.  And when “Pit to Distress” is in play, it is truly unbearable to both experience and to witness.  However, if pitocin is administered compassionately and appropriately it is important to know that an epidural is NOT an absolute necessity.  I have seen many women do it without an epidural and many who have done it with an epidural.  So if you have to be induced with pitocin and you desire an “unmedicated” birth, your hands aren’t completely tied.  You CAN do it.  However, I have said time and time again, I would rather a woman have a vaginal delivery with an epidural than a cesarean section without.   That being said, the pitocin and epidural partnership has a dark side too. 

 

While an epidural can help the woman relax and allow the pitocin to work more effectively, most birth attendants that practice “Pit to Distress” persuade and even bully their patients into getting an epidural specifically so the nurse can “crank the pit” without the woman objecting.  But I would like to remind you that even if you can’t feel those contractions, your baby IS feeling them.  Also, epidurals themselves CAN and DO cause fetal distress and anyone who tells you that epidurals pose no risk to the baby is being dishonest!  At my work, we nickname this the “ten by ten”.  That is, almost without fail, many women who get an epidural are is likely to experience a whopping fetal heart rate deceleration lasting approximatly ten minutes about ten minutes after she is put back to bed, which of course throws everyone into a tizzy. 

 

All of a sudden mom finds herself with her face planted into the bed, her ass in the air, a mask of oxygen on her face, an anesthesiologist pushing adrenaline into her IV to increase her blood pressure and a doctor with his hands up her vagina screwing a monitor onto the baby’s head.  Most babies do recover from said decel and go on to deliver vaginally.  But it is NOT rare for the baby to NOT recover which lands mom…you know where….in the OR.  And guess what!  Since she already has that epidural in place, why they can just cut her open even faster! 

 

Please know that I am not condemning any woman who requests an epidural in labor, especially if she is on pitocin.  I just want all you women out there to know that sometimes that epidural that they keep waving in your face is just a way for them to shut you up so they can CRANK the pit.

 

 

#6  If you feel like you are contracting strongly at least every 2-3 minutes (3-5 in a 10 minute period) and the nurse or birth attendant desires to increase your pitocin, you might want to consider requesting a vaginal exam. 

 

Now, I know limiting vaginal exams is very important to many women as they are invasive and uncomfortable/painful.  I completely understand!  However, if your care provider wants to increase the pitocin and you feel it is unnecessary, asking for a vaginal exam is a way to reveal if you are making any cervical change.  If you ARE making cervical change then there is no real need to continue to go up on the pitocin!  Remember the TRUE goal of pitocin administration is to stimulate an effective labor pattern that causes cervical change.  It is NOT (despite how many birth attendants practice) just about getting a patient to “max pit.”  Every woman is different! 

 

Lastly,

 

 

#7  You could always try writing something about pitocin administration in your birth plan. 

 

For example: “If deemed necessary, I would like to try non-pharmacological methods of labor augmentation and induction including (blank) first before resorting to pharmacological methods.  However, if my birth attendant and I agree that pitocin will be administered to me, I request that the pitocin be administered following the “low dose” protocol and is increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.”

 

I will be very honest with you.  If your birth attendant or hospital does not practice in this way, it is doubtful that this request will be granted.  However, I suppose it can’t hurt and is worth a shot!  At least it can provide a sympathetic nurse with another platform on which to argue with the birth attendant if necessary (like, “But Doctor X, your patient has specifically requested a low dose pit protocol!”

 

This should be a last resort!  Remember, writing something in your birth plan does not guarantee you it is going to happen if your birth attendant doesn’t practice that way!  Please refer back to point #1 about choosing the RIGHT birth attendant for you!!! 

 

 

All My Best,

NursingBirth

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61 Responses to ““Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions”

  1. […] check out my next post!  “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interve… Possibly related posts: (automatically generated)Living Statues Go on DisplayBabes’ Blog, […]

  2. cpster Says:

    Thank you so much for taking the time to share your wealth of knowledge. I’m printing off many pages to take with me to the hospital!

  3. Zoey Says:

    Nursingbirth-

    Thank you for your post! This is a much more detailed response than I ever expected and I am so grateful for it. I will be sure to pass your blog information along to my friends. Thank you for all the information that you share with us.

  4. Johanna Silva Says:

    You are awesome! Thank you! I have been saddened by my realization that my hospital stay was not as great as I thought it was at the time. My nurse didn’t check on my uterus and kept increasing the pit every 15 minutes. She shut it off once per my request. It was then turned back on, once I got the epidural, but my poor Arianna was in distress the entire time. So was I. I didn’t know better. I was in such horrible, constant pain that I did a pathetic job advocating for myself. On the upside, I am very hopeful that if we get pregnant, labor and delivery will be a completely different story! Speaking of, I get the impression that I can’t pick my birth attendant at my hospital. It’s who ever is on call that night. Could be one of the 4 ob’s I know; it could be someone else. How common is this? Very distressing to me. I want someone I know, trust, someone whose track record shows she/he is who I am looking for.

    • NursingBirth Says:

      Johanna Silva, I am hopeful too for you that with your new knowledge and all the research you are doing that things can be different for you! At least you have a much better chance of it being more educated!

  5. Thank you sooo much for this extraordinarily helpful post! I have, in particular, a good friend contemplating a vbac and this info may prove very helpful to her.

  6. Jill Says:

    What do you do when there are varying opinions between physicians at a practice? Say you are seeing a CNM practice for care. You like two of the five midwives because their beliefs line up with yours. The other three, not so much. But it’s the luck of the draw when it comes to who is going to be on call when you go into labor. What happens when you get the physician that you don’t gel with?

    • NursingBirth Says:

      Jill, I have no idea. Women ask me this all the time. In fact, a few comments before yours Johanna Silva basically asked the same question. The doctor or hospital based midwife that you see the most/like the best may not be “on call’ that night. You could always ask them for their personal home phone number and ask them if they will come in special for you regardless of if they are “on” or not. I know some docs/midwives that I work with that will do that if they can for patients they bond particulary well with. However there is no guarantee that they will do this for you. You could consider hiring a doula, that way, you know that you are basically guaranteed that you will have someone besides your family/friends there as an advocate for you that you have met and formed a relationship with previously. Or you can do what more and more women are doing around this country: seek out the help of a midwife and plan a home birth.

      • Melissa Says:

        I was able to find a homebirth midwife with hospital privileges. She was the backup midwife for a midwifery group practice which had privileges at the local hospital. I could have just gone with the group practice, but it was important to me to have the person of my choice at my birth. I had the comfort of knowing that she, and no one else, would be attending my birth at the hospital. If any unforeseen circumstances came up that made her unable to attend me (highly unlikely, but you never know) she would send her backup midwife with whom I had met several times. I never wanted a group practice, even with midwives. Even among midwives there is a wide range of practices. I felt more comfortable having my own private midwife in a hospital setting–best of both worlds for a first-time VBAC birth. My last birth (2ndVBAC) was at home (as NursingBirth pointed out above). Hope this helps.

  7. Joy Says:

    I feel badly for you because you have to be at the forefront of this abuse, trying to advocate for patients (most of whom don’t know WHAT to advocate FOR) and keep their babies from distress.

    I’m grateful to have my OB, who has told me he does not like to section a woman whose had vag. births. But now I’m wondering about other things.

    Even though this is my 3rd baby I signed my husband and I up for the Birth Class. And my OB appointment is tomorrow. I plan on giving him my birth plan and talking it over with him, to get a feel for what he thinks.

  8. Jill Says:

    And that’s why I did. ;)

  9. Katie Says:

    Thank you for this post! It was so informative. I’m a military spouse, though, and while I am very fortunate that I do not have a high deductible the cost for that is that I cannot choose my hospital or birth attendant! So I’m glad to be learning all of this information from your blog-Thank you!

    I’m wondering if anyone can help with a question. I know that inductions are generally regarded as negative, as MANY statistics show they lead to more interventions and often c-section (as this blog as helped me see!). But I also know of women who were induced-generally 1-2 weeks after their due date-who went on to have a normal vaginal birth. So even though I know induction is NOT what one would want who is looking for a vaginal birth, are there statistics about women who are induced with pit. who go on to have normal vaginal births? Just wondering if those numbers are out there.

    • NursingBirth Says:

      Katie, when used appropriately, judiciously, and safely, a pitocin induction (where the woman is being induced for a true medical, obstetrical, matenal, or fetal reason) with a ripe cervix (if the medical condition allows…google Bishop’s score) is an instance where I support the use of pitocin. See induction has RISKS and when the benefits of the induction outweigh the risks (which is again, when the induction is being done for an actual medical, OB, materal, or fetal reason) then it is most wise and safest to end the pregnancy and induce.

      First I ask you however, is how you define “normal vaginal birth.” Because if you mean “normal” only that the baby came out of the vagina then we disagree. I invite you to check out the Society of OBs of Canada (SOGC)’s Joint position statement on Normal Birth for some definitions: http://www.sogc.org/guidelines/documents/gui221PS0812.pdf

      And for the record, when you hear stats that include inductions give you greater chance of c/s etc, they are including the women who delivered vaginally as well as via cesarean.

    • Katie, is your spouse with the US military? If so, you may be eligible to contract a volunteer doula through CAPPA’s Operation Special Delivery program. Check out the OSD website for more info:

      http://www.operationspecialdelivery.com/

  10. Emily Jones Says:

    NB – I wrote a post about Questions to Ask your Prenatal Care Provider, which lists 10 non-standard questions to help determine if your care provider is going to pull the bait-and-switch on you. This may be helpful for anyone wanting to truly test their care provider on their natural birth philosophies.

    • NursingBirth Says:

      Emily Jones, thanks so much! i’ll be sure to take a look!

    • a newbie doula Says:

      From the Adventures in Crunchy Parenting blog:

      “I’m not going to spend a lot of time on [the] subject [of Fear of Loss of Amniotic Fluid], because the error lies not in the fear, but in the determination of a true problem. Low amniotic fluid levels are indeed cause for concern. However, all too often, for fear of liability, doctors will suggest induction for anything even borderline concerning, and without considering alternative treatments or testing first… That being said, if you are told that your fluid levels are low, and then are sent for induction in which the doctor artificially ruptures the membranes, you are being duped.

      AAAHHH!!! I attended a birth where this HAPPENED, right before I trained to be a doula. *smacks forehead into hand repeatedly*

      Primip mom, sent for a NST at 5 days past EDD. 8 days past, had a ‘trickle event’ that she didn’t think was ROM (we both think it was, now, hindsight being what it is). Her OB, who up to this point had approved everything on her birth plan and supported mom’s wish to do Bradley Method for her pain management, does an ultrasound at next appointment (a day later, as chance would have it) and proceeds, with frightened words and body language, to ship mom to L&D to induce for low amniotic fluid despite the fact that mom mentioned ‘peeing’ herself the day before.

      Mom is scared poopless at this point, and ended up tossing her birth plan completely, acquiescing to everything the OB wanted to do, despite my urging to ask for a litmus test for fluid.

      No gush resulted from the OB digging around inside her with the amnihook. Then the EFM showed a decel, frantic staff puts mom on oxygen – I’m the only one suggesting that mom get off of her back where she’s been lying for at least 20 minutes.

      Unable to break membranes, the OB stood up and says, “Mom, I think it’s time to start Pitocin,” in ominous tones.

      Baby was born (vaginally) five hours later – with scratches on its scalp.

      (Not related to low fluids, but just as infuriating to me: OB pulls the cord during placenta delivery. We’re doting over the newborn when I hear OB say, “Oops,” from between mom’s thighs. Manual deliver of the placenta ensues. Tiny tear requiring no stitches turns into a 2nd degree tear. *more forehead banging*)

  11. wb Says:

    I’m wondering how to go about “doctor shopping.” The awesome CNM we used for a hospital birth center birth last time is no longer delivering. We switched to her at 6 months pregnant on the advice of our Doula, but I’d like to avoid a last-minute switch next time! I have a list of possible providers for if we get pregnant again, but I’m wondering how to approach the process. I.e. Should I make multiple first trimester appointments (and won’t my insurance LOVE that)? Call and ask for a informational appointment? Is there such a thing?

    • NursingBirth Says:

      wb, I am SO Happy you are “shopping”. I always think of that song “My momma told me you better shop around”! Hahah! Anyways, most practices/birth attendants will do a no charge informational appointment. If they don’t, that’s a strike in my book. Personally, I don’t see there being any reason to wait until you get pregnant. You can do these informational meetings right now or when you start trying to get pregnant. Why wait???!! Also, some practices like you to come in for a “preconception” appointment anyways to make sure you are in good health and if you have any health problems, trouble shoot ways to ge them undercontrol before you get pregnant. So start shopping!!!

  12. Jessica Says:

    I think this post should be read by every pregnant woman. And the previous one. AND the comments. THANK YOU
    I know your blog can really make a difference in helping mothers have the birth they deserve, thank you for taking the time to do it.

  13. […] always, Melissa over at Nursing Birth has written two FANTASTIC posts, Pit to Distress Part I and Part II about this topic.   She gives examples, and in her “Tell it like it is style” she […]

  14. Erin Says:

    I wonder too if you could chime in with some information on general guidelines for interpreting your doctor’s reasons for inducing. While some reasons for inductions (aren’t you tired of being pregnant?) are obviously bogus, I bet many physicians come up with reasons that sound good on paper. To me that’s the scariest thing about advocating for myself. Doctors make everything they want to do sound medically vital. Your amniotic fluid is low, your baby is too big, etc etc etc.

    Also, just as a general rule, if you doctor tries to pressure you into an induction at 37 weeks (especially if s/he uses the “aren’t you tired of being pregnant” line), this is a sign that you do NOT want this dr to deliver your baby. It is not too late to try to find another practitioner. . . I saw a really sad “A Baby story” the other day (I know, I know!) where the mother was induced early (I missed the reason why, but she didn’t seem to be in medical distress) and her baby ended up with immature lungs and spent two days in the NICU.

    Re questions about practices: I know it’s difficult to be in a situation where you can’t choose exactly who you get – but does your hospital really only have one group practicing there? Most hospitals I know have more than one doctor or group with admit privileges. And definitely, get a doula so you’ll have some continuity.

  15. Aisha Says:

    i’m 37 weeks pregnant and I’ve been reading on the topic a lot and going to the childbirth classes and all and I’m delivering with a CNM at my hospital where I hope that I will have a natural delivery with minimal interventions (or no interventions at all).
    It is very discouraging that women that I know tell me to go for the interventions. Its crazy. My cousin just told me to “forget about a natural delivery and go for the epidural because you don’t need to prove anything to anyone” I was insulted, I’m going natural not because I want to prove how strong I can be, but because I know that my body is 100% capable of delivering naturally without possibly harmful interventions. My mother is the one with the lowest faith of all and she has kept on telling me that my doctor should measure my pelvis to make sure that I can deliver naturally, excuse me what?? She had 2 c-s because since the begining of pregnancy her doctor told her that she was too small for natural delivery which is not true and because her mom had a c-section, she was bound to have a c-section.
    the list goes on…everyone tries to discourage me from my plans. Oh and there was another lady that told me that she had the best labor because she doesn’t remember anything, they gave her so much demerol when she arrived to the hospital that all she remembers is holding her son hours after delivery. Shocking!

    Oh, don’t get me started on breastfeeding, a lot of women discourage you on that end too.

    I don’t think that its doctors only that discourage women’s ability to give birth without interventions, I think women in this country have relied sooo much in “what the doctor said” that they don’t think that anyone is capable of having a normal/natural delivery. And the only stories that you hear from other women are birth horror stories, no one tells you about the good ones!

    Its frustrating, but i’m sticking to my guns. My father and my husband, strangely enough are the only ones encouraging me to have a natural delivery and have faith that I can do it without help.
    Anyway thank you for your blog, it keeps me holding strongly to my beliefs.

    • NursingBirth Says:

      Aisha, You write:

      I don’t think that its doctors only that discourage women’s ability to give birth without interventions, I think women in this country have relied sooo much in “what the doctor said” that they don’t think that anyone is capable of having a normal/natural delivery. And the only stories that you hear from other women are birth horror stories, no one tells you about the good ones!

      I couldn’t agree more!! I am so sorry that you have so much negativity around you! Unfortunately you are not alone! It is SO INCREDIBLY FRUSTRATING when I hear people say things like “Oh, why do you want a natural childbirth! Are you trying to be a martyr?! You’re crazy! What have you got to prove?!” AHHHH! I agree with you it’s like, “Ummm NO! I just believe the risks outweigh the benefits for both me and my baby and I have trust in my body!” Sometimes I feel it comes from their own insecurities about their own experience. After all, NO ONE wants be believe that they didn’t give their baby and their body the BEST chance and the best experience! They get defensive. And you’re right, they get defensive about breastfeeding and parenting too! I already hate “Mommy Wars” and I am not even a mommy yet!

      Please know that you are NOT crazy!! Thank you for reading and for sharing. I know that there are other women in your situation who will find comfort in your comment because they too are going through the same things!

  16. Katie Says:

    Nursingbirth- Thank you for clarifying! I suppose when I said ‘normal vaginal birth’ I was thinking of my two sisters. They were both 40 weeks, cervix was ripe, and wanted to deliver sooner rather than later. When I think of ‘normal’, I was thinking that once they got the Pit. she didn’t need any further interventions, her labor progressed naturally after the Pit. was started, and she went on to have a vaginal birth as though her labor had started naturally. I wasn’t sure if this was the norm, because I read the statistics about inductions leading to more and more interventions, which I don’t doubt! I’m just wondering about it because I don’t have a choice in hospitals or attendants, what to do if they try to push the pit. on me! Thank you!

  17. Erin Says:

    New data points: My cousin had a baby today (yay!) but she was induced. As soon as I heard that I was suspicious – she’s “overdue”, but only 5 days post-EDD. My family told me that she “had” to be induced because she was “late” and also they didn’t want “the baby to get any bigger” because my cousin is small. I saw that coming, because all along the doctor had instilled this weird fear in her about the baby becoming too “big” for her. And it’s true, she’s not a big woman, but give me a break. I know you won’t be surprised to hear this – the baby 6 lbs 8 oz! At 5 days overdue. Luckily she was able to have a vaginal birth and everybody is doing well. But the whole thing made me so angry.

    I think Aisha is totally right. there is so much hostility to natural birth & even breastfeeding in this country. Women who want this things have to fight so hard them; it’s exhausting. And it makes me livid that doctors perpetuate this false and dangerous information to their patients.

    • NursingBirth Says:

      Erin, I hear you sister! I always get suspicious too when I hear someone “had” to be induced. Not that there arent reasons to be induced but the vast majority of the time it is unnecessary. Glad everything worked out for her of course but you are also right…I am NOT at all surprised the baby was only 6lbs 8oz! GRRRRRR!

  18. Anne Says:

    Hey there!

    Thanks for these great posts!

    Just a quick comment, to get people thinking.

    I know the docs have their textbook protocol that they think labor should follow, but in reality labor patterns vary widely (considering what you wrote, I’m probably preaching to the choir).

    Anyhow, I successfully delivered a VBAC baby entirely naturally a couple of years ago. My labor was slow and drawn out (considering my membranes ruptured sponstaneously to start labor, I am counting from there). I definitely didn’t follow the Friedman curve. However, true active labor was only about 12 hours long. In transition, my contractions were double peaking and I was shaking, but they were 8 min apart. They were definitely doing something though. Pit was not needed, the contractions were working and the baby was born vaginally without incident. In fact, due to his young age (36w6d) he might not have tolerated pit well.

    I just hate to see a standard like ctx’s less than 5 min apart, because some women and some babies don’t need them that close. In my case, I truly feel pit might’ve stressed me and the baby, and possibly my scarred uterus, and would have essentially been the result of “failure to wait.”

    I realize you work in a hospital and there are certain protocols/ constraints you have to follow, and it seems to me you do a wonderful job of trying to protect both patients (mom and baby)…it’s the hospital protocols that need to change to recognize the fact that each mother, each baby, each labor is different. Right now, even the humane way of administering pitocin you suggest does not (IMHO) really allow for individual variation.

    Just my $0.02. And please understand that I am very appreciative of what you’ve posted already, and what you are doing, I am just trying to get every woman reading this to think even farther outside the Friedman curve/ textbook labor patterns they’ve been taught. Labor does not have to follow the curve or have ctx’s every 5 min or less to be effective! :-)

    Thanks!

  19. stephanie Says:

    You forgot one: Read the dr’s orders and don’t consent to the IV until the nurse hands them to you. I actually took the file from my nurse (politely!) when discussing my induction for my vba2c to read them with the full intention of walking out of the hospital if they didn’t read as discussed with my OB. They were exactly as discussed and no one came near that IV drip w/o answering to me first. I ended up with a beautiful empowering birth.

    I learned this lesson the hard way. My first labor was induced and the dr agreed to a low dose protocol which he knew was the basis of my agreeing to the induction. I didn’t find out till the 2w pp meeting with my doula that he did the high dose – along with breaking my water at 1cm! Hence my hellish labor and first c/s. What was more traumatizing… the epidural failing on the OR table or my dr’s betrayal? The betrayal by far.

    thank you for this blog by the way. I have learned so much from you!

  20. […] “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interve… […]

  21. Brenna Says:

    Thank you for these posts. I believe that the doctor who delivered my second child (not my doctor, but the on-call doctor) attempted the “pit to distress” tactic on me. I walked into the hospital at 6:30 pm 4cm dilated, continued to contract, and an hour later I was 5cm. The doctor told the nurse to start pitocin. I said no, and that I didn’t think it was necessary. The poor nurse looked frightened, which I didn’t understand at the time. I had no idea that she would catch hell for my refusal. After talking to the doctor (who I still hadn’t seen at this point) she said he wanted to break my water. Again, I said no. And, being naive, I was really confused as to WHY this doctor kept wanting to do all this stuff to me when I thought I was progressing wonderfully. When the doctor finally stumbled in for the delivery (a mere 6 hours after I’d entered the hospital) he was rude and barely looked at me. I pushed twice and delivered a healthy 8lb. 9oz. boy. Healthy, that is, except for the collarbone that the doctor managed to snap. I still believe (7 years later) that doctor broke his collarbone because he was frustrated that I wouldn’t follow his “plan”, so he had to stay at the hospital later than he wanted. I hesitate to say that it was INTENTIONAL, but it was definitely a result of him being angry, and therefore not gentle.

    This doctor, thankfully, stopped delivering babies a few months later.

    • NursingBirth Says:

      Brenna, WOW what a story!! You are an inspiration to me for sticking your ground and advocating for yourself! It is SO HARD to advocate for yourself when you are trying to concentrate on your labor and staying loose and relaxed through the pain. It is INFURIATING that they kept after you even though you were progressing but that happens ALL THE TIME around this country! Women need to realize this!!!! THANK YOU for sharing!

  22. enjoybirth Says:

    Oh, I love this post! Great points, all of them.

    I will say that as a doula, I have never had a nurse on their own explain about pitocin and how they up it. I always ask or have the parents ask and they they explain it. Maybe they would have explained on their own? I am not sure. But how great that YOU do!

    I think that your number 1 is so key. Choose your care providers CAREFULLY! If you have a good low intervention one, then you aren’t fighting them every step of the way to have a normal birth. Also if they suggest an intervention, it is easier to know it is justified.

    I would just add so moms know. Even if you don’t want to hire a doula, know that we are a great resource. I am happy to talk to expecting moms, make recomendations about hospitals and care providers. I SEE what happens, I know the best hospital and low intervention care givers in the area. I am happy to share that information with ANYONE, even if they don’t want to hire me. I imagine most doulas are the same.

  23. […] also visit Nursing Birth’s Top 7 ways to protect yourself from unneccesary and harmful interventions. For other great tips!  (Choose your Care Provider Wisely is number 1) Possibly related posts: […]

  24. Amy Says:

    Thank you so much for this post, nursingbirth. I am a Bradley childbirth instructor and am just starting up a local chapter of Birthnetwork National. I was wondering if I could make copies of this post for women who come to me?
    Keep up the great work! The internet is an amazing place to start a revolution.

    • NursingBirth Says:

      Amy, YEAH!! I wish you the best of luck with BNN.

      About making copies, am am very honored and flattered! I am totally down for it but I have a question. Would you be actually just going to my website and printing off that post (I’m okay with that) or would you be copy and pasting my list and making your own handout (a bit more worried about that). I basically would want to assure that 1) the handout has my website on it (http://nursingbirth.wordpress.com) so that women can visit my blog for more information and 2) NursingBirth is given credit as the author.

      THank you for doing all that you do for women!!!!!

  25. Amy Says:

    Thanks for posting this!
    I would also mention that what you recommend is exactly what is taught in Bradley Childbirth classes — How to stay healthy and low risk.

  26. sarah Says:

    I just want to mention that the mothering.com discussion forums under finding your tribe is a great place to get opinions about birth providers. I have found it to be an invaluable resource myself not only for finding a midwife, but also to find my sons pediatrician. Sadly, you may find that in your area there just aren’t a lot of options, but even if you end up with the less than perfect provider you generally can find out what to “be on the lookout” for.

  27. sarah Says:

    Sorry for the double comment but this line stuck out to me so much

    “you might be having contractions every minute but the machine is not registering them.”

    This is exactly what happened to my friend. She truly desired to birth without pain medications. Her water broke and after 6 hours (*sigh*) her doctor started pressuring her to use pit b/c she wasn’t progressing fast enough and her water had been broken for too long (grr). Anyways, before the pit she said her ctx were totally manageable mostly b/c she got breaks. As soon as the pit started her boyfriend would say, okay the ctx is over (according to the monitor) and she was saying “NO IT ISN’T” she was no longer getting any breaks between ctx so she ended up getting the epidural asap.

    • NursingBirth Says:

      sarah, i hate when family/partners “monitor watch”. it often does little to help the woman cope and also often makes the woman feel like she is not getting the attention.

  28. […] with; a triad of posts from L&D nurse Melissa at Nursing Birth — Pit to Distress part 1, part 2, and understanding the pitocin dosage; former L&D nurse now new CNM Rebirth Nurse; and finally, […]

  29. Kelly Says:

    Your accounts make me so very thankful I listened to my gut and switched to a midwife practice 1/2 way through my pregnancy. I am so sorry that you have to deal with doctors like the ones you’ve described. The idea of women having to have a c-sect just because their doctors think they’re god makes my skin crawl!

    Thank you for showing us what can and does happen. You help make women aware!

    • NursingBirth Says:

      Kelly, I am so appreciative of moms like you who comment on thier own experiences with switching to a different birth attendant. I can imagine how scarey it must be to decide, often in the third trimester, to switch birth attendants! Thank you for being a real life example of how it can be done!!

  30. Karen Joy Says:

    Thank you for this post. I found it clicking through as Nicole/It’s Your Birth Right! had left a comment on my blog.

    I had a great, low-intervention OB for my first four children, and birthed with no Pit, no pain meds, no interventions. But then my wonderful doc retired. For my 5th baby, I used the doctor that was in practice w/ my former OB. He had actually delivered my 4th baby, as he was on call when I went into labor, and was *fantastic.* However, for my prenatal care with my 5th, red flags were going up right and left as he didn’t seem to care about what was important to me, and started pushing EARLY for me to be induced. I called a midwife whose daughter had babysat for me, and asked her to recommend a doc. She did, and I switched when I was at 30 weeks, which was somewhat stressful, but such a good decision.

    I very much agree with your point #2 — if you can find a “back door” way of finding an OB, someone in the birthing community who has experience with him/her, you will lessen your chances of bait-and-switch doctors (which a friend of mine is experiencing — her birth plan states not to induce unless absolutely medically necessary, and at her last appt — 38 weeks — he told her to schedule an induction on her way out the door, as he was going on vacation the week after her EDD.)

    My doctor was paaaaaaatient with the birth of my 5th, even when my L&D nurse was not. I appreciate the fact that nurses are accountable to hospital practices, etc. But, the only thing that was really rough about that birth was that I had to repeatedly decline the nurse’s offer of meds, Pit, calling the doctor, etc. My doc stuck by my insistence to not have Pit, nor any other intervention. Even though I was “stuck” at 8 cm for a five hour stretch, I felt great, and felt that labor was progressing fine, even though technically, I was failure to progress. Only after five hours of FTP, my doc said, “Well, I think I’m going to need to rupture your membranes.” I went to the bathroom to think and pray, went into transition, and baby was born 15 minutes later, no AROM necessary.

    I was a wee bit upset that he suggested AROM, but in the grand scheme of things, I think he did wonderfully… The more I read about impatient doctors, the luckier I feel that he was so much on my side.

  31. Vanessa Says:

    # vacuum or forceps-assisted vaginal birth; # cesarean surgery; Thank you. The information you have shared is so beneficial to women, mothers and soon-to-be mothers as well. It is unfortunate how inadequately prepared some new mothers are when it comes to their bodies and the methods used to deliver their child. Forcep assisted deliveries can not only be dangerous for the child they also cause some serious (undisclosed) damage to the woman’s anatomy. I have worked with a good number of women that experienced tears in the vaginal tissue that has not only caused sexual dysfunction, but also bowel and bladder issues (to perfectly young and healthy women). It is always best to inform yourself and ask questions, regardless of how many times your doctor has done this before. It is your body and your baby, do what is best for you both! http//

  32. Autumn Says:

    The only problem I have with the advice to shop for birth attendants is not everyone lives in an urban area and can do this. Some people have situations where all the doctors in town share call so even if you do choose a low intervention practice you may STILL get stuck with an impatient birth attendant.

    For me alternative hospitals are too far away to truly be a safe alternative. I’m fortunate, I had all my babies before the poop hit the fan and had great births, now folks are not so lucky

  33. Sarah Says:

    I was definitely having pit upped on me every 15 minutes and I never stopped contracting. I would ride the wave down and then go instantly back up for hours on end. They had it so high with my second son that he was born in under 5 hours. *sigh*

    Makes me glad I am never delivering in a hospital again ;-) Home birth, here I come!

    I’ve heard it’s true, and maybe you can address it in another blog, but if I put on my consent for treatment form that I refuse Pit or an IV that they can’t do it. It makes sense that they can’t, but would I catch hell for that?

    Thanks!!

  34. Sharyn Says:

    The fact is, though, that many women do NOT have an option for whom will be delivering their children. Women in the military, for instance (as I am) MUST go to a military hospital or risk losing both medical coverage and active duty eligibility. Others have insurance that will only allow them to go to a practice in a hospital, where they may not even see the delivering practitioner until the day of birth. Unfortunately, due to legalities of insurance and the reality of diminished funds, many of us are forced to use the physician available to us, not necessarily the one we would pick. I really wish this wasn’t the case for me, as I’ve had nothing but bad experiences with military medical, but it’s either that or risk losing my family’s only source of income if they find out I used a civilian caregiver.

    • fairflowers Says:

      I’m a midwife and did a birth for a lady who was active duty, as was her husband. She transferred to me at 32 weeks because she didn’t like what she was hearing from her doctor. Neither of them suffered any repercussions from getting their care from me and she had the birth she wanted.
      Furthermore, you have to question a government that tells you where to birth and with whom, and threatens you with losing your job if you don’t comply. Sounds kinda tyrannical to me, doesn’t it to you? It’s your money–spend it on the care that is best for you. You DO have a choice.
      We often have women who have insurance, but they choose to pay us for their care because they know they will get the best care possible and have a say in it! It’s worth it. And many midwives do a certain number of reduced fee or free births each year to help moms that otherwise could not afford their services. Ask. Some will also barter.

  35. Angie Says:

    I was an L&D nurse in Miami for 5 years where the current c/s rate is over 50%. Some hospitals publish a 70% c/s rate. I tried to be a patient advocate but it is so hard fighting the whole system. I had docs tell me in the lunch room that they had an important golf game so they needed to do this. Then they’d go in the room, lie to the patient, say, your baby’s never coming out this way, you’re going too slow, even after I had documented progress.
    The patient believes them and says “oh thank you Dr. for saving my baby.”
    After working in L&D there for so long, I began to feel guilty about being a part of this. So I became a Nurse-Midwife in a birth center, which was so much better. I’m contemplating returning to the hospital, but so scared of the environment there. Most patients don’t realize how bad it is, and it won’t change until women speak out.
    Thanks to all her for voicing their opinion, but if you feel passionately, you should do more. You should join midwife support groups, give money, lobby your representatives to make sure to keep your birth options in place, and keep midwives reimbursed.
    One disheartened midwife, wishing to have more hope


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