Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Don’t Let This Happen To You #22: Gina & Tony’s “Elective” Primary Cesarean Section PART 2 June 12, 2009

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 1:16 PM
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Continuation of the “Injustice in Maternity Care” Series

 

Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!”  Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  If haven’t already read it, I invite you to check out part 1 of this post: DLTHTY #22: Gina & Tony’s “Elective” Primary C/S  PART 1.

 

 

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And now the story begins…

 

 

Not too long ago I was part of an absolutely outrageous and unnecessary cesarean section.  I arrived at work at 11:00am as usual and noticed that I had been assigned to the OR team.  My hospital averages about 10-15 births per day, and depending on the day, 4-6 of those births are by cesarean section…sometimes more.  Monday through Friday from 7am-3pm we have an OR team comprised of about 5 nurses or so, that handle all of the scheduled cases and even any emergency cases that happen during the day shift.  However, if there is a call in for the OR team or they have a particularly large case load (for example, a full schedule of scheduled cesareans plus some unexpected add-ons) I often get pulled off the floor to join the surgical team. 

 

So after reading the assignment I moseyed on down to the surgical wing to get the scoop from the OR charge nurse, Linda.  Linda informed me that I would be scrubbing the 11:30 case (that is, assisting the surgeon by passing him/her instruments and keeping an accurate count of all instruments, sharps, and sponges).  Next I looked over the patient’s chart so I would better understand what to expect during the case. 

 

The patient was Gina, a 24 year old G1P0 at 39.2 weeks with an unremarkable past medical history (tonsillectomy at age 6, mild exercise induced asthma) and a normal healthy pregnancy.  She and her husband Tony were expecting their first baby, a boy that they planned on naming Giovanni after her late grandfather.  Gina was about 5’6” and approximately 155lbs while her husband was about 5’10” and slender.  I scoured her admission assessment for a medical indication for her cesarean section.  Did she have active genital herpes?  Nope.  How about placenta previa?  Nope.  Was she breech, brow, or transverse lie?  Nope.  Problems with her first delivery?  Well no because this was her first baby.  Did she undergo previous extensive abdominal or uterine surgery?  Nope.  Was she abducted by aliens who sewed her vagina shut?!  NO!  NO!  NO!

 

And as I shut her chart to go and find her nurse and get some answers, my eyes fell upon her name plate and everything started to make sense….she was Dr. M’s patient!!!!  She was an elective primary cesarean section!  Let me digress for a moment to explain a little bit about Dr. M so that you get a better idea of the situation and why I just knew that Gina was scheduled for an elective cesarean. 

 

 

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During my first week off of orientation as an L&D nurse, I admitted a patient of Dr. M’s for a repeat cesarean section.  I asked a fellow nurse, Sarah, if she could tell me a little bit about Dr. M since not only had I never worked with her during a birth before, but I had never even seen her in the labor wing during my entire 12 weeks of orientation.  Sarah looked right at me and said, “Let me put it this way.  Dr. M performs so many c-sections that it is almost as if she finds it personally offensive for a woman to deliver vaginally.”  I almost spit out my juice when I heard that!  Turns out, however, that she wasn’t exaggerating. 

 

Dr. M has the highest cesarean section rate out of any of the obstetricians that have privileges on our unit clocking in at a whopping 74% in 2007!  She has almost a 90% rate of vacuum assisted deliveries since she uses a vacuum on every cesarean and almost every vaginal delivery.  (And to be very honest, the only time she doesn’t put a vacuum on the baby’s head during a vaginal delivery is if the mother has a precipitous delivery and the nurse “accidentally” (*wink, wink*) forgot to bring a vacuum into the room!  Also whenever she uses a vacuum she cuts a giant episiotomy as well so you can do the math on her episiotomy rate!)  It is actually a joke among the residents and nurses on the floor (a really sad, sick joke, but a joke nonetheless) that Dr. M’s patients don’t ever have vaginal deliveries; they just have “failed cesareans.” 

 

Dr. M is one of only two doctors on the floor that will do primary elective cesarean sections and even so, the other doctor that will attend them will agree to it only in very rare circumstances.  But what exactly is an “elective primary cesarean section?”  Is it the same thing as a “maternal request cesarean section?”  That is, if a patient is scheduled for an elective primary cesarean section, does it automatically mean it was because it was by the patient’s request?  Are they the same thing?  Interchangeable terms?  And what does elective really mean?  Before I discuss the answers to those questions let me finish Gina & Tony’s story.

 

 

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At this point I’m pretty frustrated.  It has been my experience with Dr. M that if her patient does not have a true medical indication for a cesarean section that she will literally make one up in order to convince the patient that a cesarean is the best way to go.  Think I’m exaggerating?  Well when I finally entered Gina & Tony’s room to introduce myself I found out the real scoop straight from the patient’s mouth.  After introducing myself to Gina & Tony and explaining my role as the scrub nurse, we got to chatting about her family, her job, and her pregnancy. 

 

 

Me:  “So how has this pregnancy been for you so far?”

 

Gina:  “Great!  I mean I had a little bit of morning sickness in the beginning but other than that everything has been great! 

 

Me:  “Is little Giovanni going to be the first grandchild for either of your parents?”

 

Gina:  “Oh well not for my side, I’m from a big family.  But he’ll be the first grandchild for Tony’s parents.”

 

Me:  “Oooh!  How exciting!!  It is so nice to hear that everything has been going well for you this pregnancy!  So what is the reason that you are having surgery today?”

 

Gina:  “Well last week I had a sonogram to measure the baby’s weight and it showed that he was really big, like over 8 lbs!!!  Dr. M also did an internal exam and said that I didn’t have enough room in my pelvis to give birth to a baby that big.  And she was my sister’s doctor too.  My sister had to have a cesarean after like two days of labor.  Dr. M  tried to induce her but her cervix just wouldn’t dilate past 1 centimeter so she had to have a cesarean for her first baby.  And for her second baby Dr. M just recommended a cesarean because she just can’t dilate.  So we were figuring I’m probably the same way too.  And I mean, I can’t give birth to no 8 lb baby!  Oh lord no! 

 

Me:  [dumfounded & speechless]

 

At that moment the anesthesiologist entered the room to go over what to expect during the spinal and I just said “Well I’ll see you both back there!” and left the room. 

 

I ran to the chart to find the sonogram report.  The estimated fetal weight per the report was 4025 grams (which is approximately 8lbs 14oz).  And sure enough in Dr. M’s admission note under “preoperative diagnosis” the following was written in black and white: elective primary cesarean section for suspected fetal macrosomia.

 

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Okay, okay, okay, there are SO MANY things WRONG with what Gina was describing to me that I felt like I had been hit by a Mack truck.  Let’s take them one by one shall we!

 

 

FACT #1:  Third trimester sonogram reports are imprecise and inaccurate since they can be off as much as 2 POUNDS and they notoriously overestimate the fetal weight.

 

“Weighing the newborn after delivery is the only way to accurately diagnose macrosomia, because the prenatal diagnostic methods (assessment of maternal risk factors, clinical examination and ultrasonographic measurement of the fetus) remain imprecise. Leopold’s maneuvers and measurement of the height of the uterine fundus above the maternal symphysis pubis are the two primary methods for the clinical estimation of fetal weight. Use of either of these methods alone is considered to be a poor predictor of fetal macrosomia; therefore, they must be combined to produce a more accurate measurement. Ultrasonographic measurement of the fetus serves as a means to rule out the diagnosis of fetal macrosomia, which may aid in avoiding maternal morbidity, but is considered to be no more accurate than Leopold’s maneuver.” 

~American Academy of Family Physician’s (AAFP) publication of ACOG Practice Bulletin No. 22, November 2000, Obstetrics and Gynecology

 

 

FACT #2:  You cannot accurately determine the size of a woman’s pelvis during labor by doing a vaginal exam before labor begins.  The human body naturally releases hormones as it prepares for and begins labor which act to relax the joints and ligaments of the pelvis, increasing the diameter and flexibility of the pelvic outlet.  This type of misdiagnosis of cephalopelvic disproportion (CPD) accounts for many unnecessary cesareans performed in North America and around the world annually.  Also the sutures of a baby’s skull are not fused at birth for the very important reason of allowing molding of the baby’s head through the birth canal. 

 

 

FACT #3:  Labor induction increases a woman’s risk of cesarean section, especially if the woman’s cervix is not yet ripened and ready for labor (a.k.a. a Bishop’s score of less than 6 for a first time mom and less than 8 for a multiparous mom).  Therefore if a woman undergoes a cesarean section after a labor induction at 1 centimeter of dilation because she “can’t dilate anymore” it was the induction that failed NOT her body. See:

 

1)     Bishop score and risk of cesarean delivery after induction of labor in nulliparous women.

 

2)     Risk of cesarean delivery with elective induction of labor at term in nulliparous women.

 

3)     Elective Induction of Labor by Henci Goer

 

 

 

FACT #4:  According to the ACOG published practice guidelines, “suspected fetal macrosomia” should not be considered as an indication for cesarean section unless the estimated fetal weight is greater than 4500 grams (9lb 15oz) for a diabetic mother and 5000g (11lb 0oz) for a non-diabetic mother, and even so maternal risk factors and birth history must also be taken into account.  The ACOG committee (Practice Bulletin No. 22, November 2000, Obstetrics and Gynecology) provides the following recommendations for the management of fetal macrosomia:

 

Recommendations based on good and consistent scientific evidence (Level A):

 

* The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold’s maneuvers).

 

Recommendations based on limited or inconsistent scientific evidence (Level B):

 

* Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.

   

* Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes.

   

* With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery.

 

Recommendations based primarily on consensus and expert opinion (Level C):

 

 * Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g in pregnant women without diabetes and more than 4,500 g in pregnant women with diabetes.

   

* Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery.

 

 

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So long story short, Gina had her cesarean section and I felt like I was going to cry the entire time.  (Sometimes I get myself really worked up about these types of injustices!  I know, I know, many of my colleagues tell me I need to learn to relax but turning the other way when this type of selfish and reckless obstetrical practice is going on in my community is just not something I can bring myself to do!)  Since I was the scrub nurse I was already scrubbed and in the OR before Dr. M even showed up to the case and since she blew out of that OR before we could even transfer the patient off the table to the stretcher, I unfortunately didn’t even get a chance to confront her about it.  And to be honest, I have seen her chew out so many nurses that I don’t know if I could have even stood talking to someone so irrational. 

 

Oh!  I can’t forget to tell you the best part of the story!  Dr. M is notorious for cutting the smallest possible incision, which one would think is a good thing, however, she cuts them so small that she always “has” to use a vacuum to pull the baby out of the uterus (and there is often a lot of straining and pulling and tugging involved on that little baby’s head!  It makes my stomach turn.)  She then, of course, brags to the patient about how “cute” her small little “smile” is (referring to the bikini cut skin incision the patient is left with.)  It really makes me sick when I hear her say that. 

 

So after the baby was delivered and Dr. M was suctioning her out with the bulb suction, I stared at the baby and thought to myself, “This baby is no where NEAR 9 pounds!”  And sure enough when the baby was weighed moments later, the red digital numbers burned into my brain as I saw them flash up onto the screen…

 

7  POUNDS,  9 OUNCES

 

 

And to top it off, as Dr. M saw the weight for herself as that little baby wiggled around on the scale, she poked her head over the drape towards Gina and said, and I quote, “Well she’s just a bit smaller than we first thought, but Gina, I think you really made the right decision.  You don’t have a lot of room in here.  You wouldn’t have wanted an emergency cesarean now would you?”

 

AHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!

 

As if she could tell how much “room” she had in her pelvic outlet from staring at her uterus propped up onto her abdomen as she sewed it shut.  Wait?  What’s that smell?  Oh yeah it’s BULL CRAP!

 

 

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In conclusion let us review the definitions of some of the terms I have been referring to throughout this post.  Although one of the problems in obtaining accurate research on the phenomenon of “elective primary cesarean section” is that there is no standard universal definition, I have decided to use the following definitions after extensive research on the subject which will be presented in Part 3 of this post.  So for the sake of discussion on THIS blog, I ask that the following definitions be considered:

 

* Elective Primary Cesarean Section: A planned first or “primary” cesarean section in a healthy woman for the birth of a baby when there is no medical, fetal, or obstetric reason for the surgery.  May be influenced by non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability, insurance coverage, liability fears, hospital economics, efficiency, convenience, and reimbursement rates, as well as other factors not listed.  (American College of Nurse-Midwives, Position Statement: Elective Primary Cesarean Section & Citizens for Midwifery, News Release: “Patient Choice” Cesareans Almost Non-Existent)

 

 

* Maternal Request Cesarean Section or Cesarean Delivery on Maternal Request (CDMR): A subcategory of elective primary cesarean sections.  A planned (before labor begins) first or “primary” cesarean initiated by the mother with the understanding that there is no medical, obstetrical, or fetal indication requiring cesarean delivery, and after a through review of the risks and benefits of cesarean delivery vs. vaginal birth by the obstetrician, the woman’s decision is to have a planned cesarean section.  The primary decision maker for a CDMR is the woman.  (National Institute of Health (NIH) Cesarean Conference definition, March 2006 & Childbirth Connection, Listening to Mothers II Survey)

 

To reiterate, according to these definitions, it is misleading and inaccurate to assume that every woman who has an “elective primary cesarean section” actually had a “maternal request cesarean section.”  In order for a c-section to be truly considered a “maternal request” cesarean, the following FIVE criteria must be met:

 

 

Necessary Criteria for Maternal Request Cesarean Section:

 

#1  The request for the cesarean and the scheduling of the cesarean must have been made prior to the onset of labor.

 

#2  The request for the cesarean must have been initiated by the mother.

 

#3  The mother must have the understanding that there is NO medical, obstetrical, or fetal indication requiring a cesarean delivery.

 

#4  The obstetrician must personally review and assure the mother’s understanding of the risks and benefits of elective cesarean surgery vs. planned vaginal birth.

 

#5  The woman is the primary decision maker.

 

 

 

So what do you think?  Does Gina’s cesarean section fit the definition for a “maternal request cesarean section?”

 

 

TO BE CONTINUED…..

 

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STAY TUNED FOR PART 3 WHERE I WILL REVIEW…

 

* Types of cesarean sections and more differences between “primary elective” cesarean section and “maternal request” cesarean section.

 

* How 13 major health care organizations and nonprofit childbirth/maternity advocacy groups weigh in on “elective” cesarean section.

 

* An actual hospital consent form for “Elective Primary Cesarean Section.”

 

Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth May 27, 2009

Filed under: In The News,Super Comments!,Top Ten Lists — NursingBirth @ 2:46 PM
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Dear NursingBirth,

I’m a huge fan of your blog! Please keep the awesome entries coming! I am learning so much. I am just a novice birth-junkie rather than a birth professional and so am anxious to eat up all the great information you’re giving out here.

Anyhow…. Our state treasurer’s wife (that’s here in Arizona) died today in childbirth, and their baby is said to be in grave condition. They’re not giving causes or reasons. Here’s the link:

http://www.azcentral.com/news/articles/2009/05/26/20090526treasurers-wife0526-ON.html

Can you think of occurrences in hospital-birth that would end up with a dead mother and a baby in really bad condition? I’d love to hear from someone who knows her stuff. The things that came to mind for me were amniotic fluid embolism, severe uterine rupture, and cesarean gone really wrong.

Keep up the amazing work!!!
Diana

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Dear Diana J.,

 

I just read the story you linked to and my heart goes out to that family.  Unfortunately the story you linked to did not go into any details, including the most important detail which is: Did the treasurer’s wife have a vaginal birth or a cesarean section, as the risks are significantly higher with a cesarean section.  I think your question is a good one and since this story has the potential to make national headlines, I think that it is an important enough question to put as its own post on my site.  I hope, however in posting about your question that moms out there who read my blog are not unnecessarily worried or upset that we are talking about maternal death as it is still a relatively RARE occurrence when you think about all the other causes of death in childbearing women. 

 

Let’s put it into perspective.  As the Arizona Central story stated, “In late 2007, the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention, released a report showing that there were 13 maternal deaths per 100,000 live births in 2004 in the United States.” And since in 2004 there were 4.1 million births in the United States, if you do the math that would make about 533 maternal deaths in 2004.  And don’t get me wrong…that’s 533 deaths to many for sure!  However take a look at this chart published by the Center for Disease Control (CDC) entitled: Leading Causes of Death by Age Group, All Females- United States, 2004.  It shows the following:

 

Leading Causes of Death for 15-19 year old Females, 2004:

1)      Unintentional Injury (51.7%), 2) Suicide (8.8%), 3) Homicide (7.5%), 4) Cancer (7.3%), 5) Heart Disease (3.1%), 6) Birth Defects (2.8%), 7) Pregnancy Complications (0.9%)

 

Leading Causes of Death for 20-24 year old Females, 2004:

1) Unintentional Injuries (40.5%), 2) Homicide (8.4%), 3) Cancer (8.0%), 4) Suicide (7.6%), 5) Heart Disease (4.6%), 5) Pregnancy Complications (2.7%), 6) Birth Defects (1.9%), 7) HIV disease/Stroke (1.4%).

 

Leading Causes of Death for 25-34 year old Females, 2004:

1) Unintentional Injuries (25.3%), 2) Cancer (15.1%), 3) Heart Disease (8.2%), 4) Suicide (7.5%), 5) Homicide (5.8%), 6) HIV disease (4.4%), 7) Pregnancy Complications (2.3%).

 

And for women ages 35-44 years old, pregnancy complications don’t even crack the top 10. 

 

Okay so if you are a pregnant mom please know that dying of pregnancy/childbirth related complications is rare and I don’t want to completely freak you out.  But there is something very disturbing about the United States maternal mortality statistics which shocks most people when they hear it….

 

The United States ranks 42nd in the WORLD for maternal mortality rates, with 1 in 4,800 women dying from pregnancy complications in the U.S. in 2007.  That means that 41 countries other countries in the world have BETTER maternal mortality rates than the United States!

 

Many of our practices and current situations in this country, including our obsession with medically unnecessary labor induction, our over-medicalized maternity care system, the practice of defensive as opposed to evidenced-based medicine, the lack of a universal health care system, large differences in health disparities among different racial/socioeconomic groups, the obesity epidemic, and our skyrocketing cesarean section rate greatly contribute to our country’s maternal death rate. 

 

So what exactly is defined as “maternal death.”  According to the World Health Organization, “A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”  Therefore a death of a woman that died from complications arising from a cesarean section a month after she had the baby would be counted in the maternal death statistics where a pregnant woman who died in a car accident or murdered during a domestic violence dispute would not. 

 

Okay, but you are probably thinking Why?  Why are so many women dying in childbirth in an industrialized, developed country like the United States at a much higher rate than other industrialized, developed countries like Japan, many countries in Europe, or Australia? 

 

Ina May Gaskin, midwife and founder of the Safe Motherhood Quilt Project, gives us some insight into the situation in her book Spiritual Midwifery, page 455, written in 2002:

 

“According to the CDC, there has been no improvement in the U.S. death rate (which is nearly twice as high as Canada’s) since 1982.  Sadly, the CDC estimates that the true death rate is as much as three times higher than that which is reported and that half of all the reported deaths could have been prevented through early diagnosis and good care.  Given the situation it makes sense for women to avoid unnecessary surgery while pregnant or in labor.  Women double or triple their risk of dying when they have an unnecessary cesarean.  Medical mistakes do happen, even to people who are well informed about their possibility.”

 

Also Ina May’s Safe Motherhood Quilt Project website also links to a Maternal Mortality in the USA Fact Sheet that is worth checking out!

 

The 2008 documentary Orgasmic Birth (which I highly recommend renting) has a 20- minute movie clip as part of the “special features” section of the DVD that provides some eye opening statistics about maternal and infant mortality rates in the United States as compared to other industrialized countries around the world.  In this short movie clip, entitled Birth By The Numbers, Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the sobering statistics of birth in the United States today.  It is a MUST WATCH CLIP for anyone who is or cares about a mother.

 

Also, here are some articles from mainstream news sources published in response to the 2007 maternal mortality rankings that provide some insight:

 

1) More U.S. women dying in childbirth: Death rate highest in decades; obesity and C-sections may be the cause  Associated Press, August 24, 2007

2) Maternal Mortality Shames Superpower U.S.  Inter Press Service, October 13, 2007

3) U.S. ranks 41st in maternal mortality  Seattle Post-Intelligencer, October 12, 2007 

 

A flyer published by the medical journal The Lancet in 2006 entitled Causes of Maternal Death: A Systematic Review ranks the top 9 causes of maternal death related to pregnancy/childbirth complications in DEVELOPED countries as the following:

1) Other Direct Causes (21.3%), complication of the pregnancy, delivery, or their management which includes (among other things):

            -Anesthesia Complications* (responsible for about 3% of all maternal deaths by itself and includes:    management of the difficult airway in obstetric patient, aspiration of gastric contents under general anesthesia, local anesthetic toxicity, and high spinal or epidural block which paralyzes the breathing muscles of mother).

2) Hypertensive Disorders (16.1%), includes (among other things):

            -Preeclampsia

            -Eclampsia*

            -HELLP Syndrome*

3) Embolism (14.9%), includes (among other things):

            -Pulmonary Embolism (typically a complication seen post-op surgery)

-Deep Vein Thrombosis (DVT) (more likely to develop for women on bed rest or post-op surgery

- Amniotic Fluid Embolism (rare and more appropriately known as Anaphylactic Syndrome of Pregnancy)*

4) Other Indirect Causes of Death (14.4%), pregnancy-related death in a patient with a preexisting or newly developed health problem like cardiovascular disease, seizure disorder, respiratory disorder, diabetes, kidney disorder, liver disorder, obesity, etc.

5) Hemorrhage (13.4%), includes (among other things):

  – Obstetrical Hemorrhage (most common causes being uterine atony, trauma, retained placenta, and coagulopathy)

  – Placenta Previa*

            – Placenta Accreta, Increta & Percreta

            – Placental Abruption*

            – True Uterine Rupture*

6) Abortion (8.2%)

7) Ectopic Pregnancy (4.9%)

8.) Unclassified Death (4.8%)

9) Sepsis Infection* (2.1%)  (most likely to occur post-operatively but can occur post-partum or antepartum)

 

*Comes to mind for me as having the potential to cause a critical illness or death for baby as well.

**Please note mothers undergoing cesarean surgery, especially repeat caesarean surgery are MORE at risk for anesthesia complications, pulmonary embolism, obstetrical hemorrhage, placenta previa, placenta accreta, and sepsis/infection than moms undergoing a vaginal birth.**

 

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You are probably thinking, “So what does all of this mean for me?” “How can I reduce my risk?”  Both are GREAT questions.  It is important to remember that I am not claiming that 100% of maternal deaths are preventable or even foreseeable.  No one is.  I also do not want anyone to get the impression that I am blaming mothers or putting unrealistic pressures on mothers to control things that are sometimes just happenings that are an unfortunate and very sad part of life.  For example, who could have predicted a fatal postpartum hemorrhage for a healthy mom after a normal uncomplicated unmedicated singleton vaginal birth?  No one could!  But what about a mom who experienced a fatal postpartum hemorrhage after elective cesarean surgery….well that one doesn’t sit so well with me!   And which do you think is more likely?  If you guessed the latter you are correct…by at least 4 times as much! 

 

So how does a mother reduce her risk of maternal morbidity and mortality related to pregnancy and childbirth complications?  The following is a short list you might want to keep in mind.  (Not surprisingly, many relate back to avoiding unnecessary surgery.)

 

TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth:

1)      Obtain good and thorough prenatal care, keeping all of your appointments, preferably beginning in your first trimester.

 

2)      Make a conscious effort to eat a well balanced diet during conception and pregnancy that includes adequate amounts of fresh fruits and vegetables, healthy fats, and protein.  There are a variety of prenatal nutrition books out there as well as many childbirth books that have a section on prenatal nutrition.  If you don’t have one buy one or borrow one from the library!!

 

3)      If you don’t exercise, start!  Many gyms, community centers, and YMCAs offer low-impact, pregnancy-friendly classes for expectant moms.  Even a 30 minute walk three times a week will do!

 

4)      If you suffer from a chronic disease or illness or are obese, it is important to know that making appointments with health care providers and specialists that can help you to manage your disease and lose weight in a healthy way before and during pregnancy can ultimately help you to reduce your risk of life threatening complications during pregnancy and childbirth.

 

5)      Consider hiring a birth attendant that practices a midwifery model of care.

 

6)      Do NOT agree to a medically unnecessary labor induction.

 

7)      Do NOT agree to a medically unnecessary or elective cesarean section.

 

8)      If you have a history of a cesarean section, seriously consider a vaginal birth after cesarean section (VBAC) if you have no reoccurring or new reasons or medical indications for a repeat cesarean.  If necessary switch to a birth attendant that supports VBAC and has the cesarean statistics to prove it.

 

9)      Seriously consider avoiding interventions in labor that evidenced-based research have shown could increase your risk of a cesarean section, fetal distress, and infection including early amniotomy (breaking of waters), accepting pitocin to stimulate or augment contractions without trying other more natural methods for augmenting labor first, going to the hospital during very early labor, accepting continuous external fetal monitoring as opposed to intermittent auscultation for a normal healthy labor and a normal, reactive, and reassuring fetal heart rate pattern, and requesting an epidural or narcotic pain medication (especially in early labor) before trying all methods of non-pharmacological pain management techniques first.  (Check out my post: Top 8 Ways to Have an Unnecessary Cesarean Section)

 

10)   Empower yourself to make safe, healthy decisions regarding your pregnancy, your labor, your birth, and your baby by doing your own research!!  (Check out my post: Birth Resources EVERY Woman Should Know About).

 

The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!” May 17, 2009

Filed under: Ideas & Information — NursingBirth @ 1:18 PM
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Recently I have received a few emails/comments asking me about the pros/cons of delayed cord cutting.  Delayed cord clamping/cutting is the process of waiting until the umbilical cord stops pulsating (approximately 5 minutes) and/or waiting until the placenta is delivered (approximately 30 minutes) before the cord is cut after the baby is born.  In today’s hospitals, obstetricians typically wait no longer than 30 seconds after the shoulders are delivered before they clamp the cord.  Why such a short time?  Author Tina Cassidy in her book Birth: The Surprising History of How We Are Born sheds some light on the subject:

 

“Throughout history, the immediate postpartum period has been as much a victim of fashion and misconception as has labor and birth.  And standard practice still varies among countries, hospitals, doctors, and midwives. 

 

The first act that usually occurs after the slippery baby emerges is the cutting of the umbilical cord.  …The act also forces the newborn to breathe air through its lungs for the first time.  Perhaps because of the symbolism of that moment, cord cutting has been a magnet for drama, ceremony, and superstition.

 

In most hospitals today, cutting the cord is such an uneventful routine that it can pass unnoticed by the overwhelmed mother.  Doctors generally wait about thirty seconds a time period long enough, they believe, for the baby to receive all the blood it needs from the placenta.  …They then apply two clamps, break out the scissors, and often ask the father if he wants to cut between the ligatures.  Doing all of this quickly also allows for the baby to be suctioned, weighed, and swaddled, before it gets cold.  

 

Some childbirth experts argue that, rather than being guided by a clock, it’s best to wait until the cord stops pulsing before cutting, allowing the baby to receive all the blood it was meant to receive from the placenta.  They say it helps the mother as well, because the placenta shrinks as it pumps out extra blood, making it easier to deliver.”

 

Penny Simkin, author of the book The Birth Partner, also writes about this subject:

 

“The cord is often cut immediately, but a recent scientific analysis has found benefit to waiting for at least two minutes or until it stops pulsating—in five minutes or so.  Less likelihood of anemia for as much as six months exists in babies whose cords are cut late.  Until the cord is clamped or stops pulsating, blood passes back and forth between the baby and the placenta.  It goes from placenta to baby when ever the uterus contracts, squeezing blood from the placenta through the umbilical cord to the baby.  Between these contractions, with each beat of the baby’s heart, blood is pumped from the baby through the umbilical cord and back to the placenta.  This transfer stops when the cord is clamped or stops pulsating, which occurs when the blood vessels close down.  The best way to make sure that the baby has the right amount may be to place the baby on the mother’s belly and wait for the cord to stop pulsating.  Exceptions to this are when the baby needs immediate medical attention, when the cord is tightly wrapped around the baby’s neck, preventing delivery, and when you have decided on cord blood removal and storage.”

 

So what can we take from these quotes?  I believe we can take the following two things:

 

#1  Immediate cord cutting is very convenient for today’s hospital staff and birth attendants.  It allows for the birth attendant to begin inspection of the mother’s perineum and stitching up of any episiotomy or tear that may have occurred (or was cut) during delivery.  It also provides an opportunity to use a sponge stick to provide traction on the placenta (a.k.a. slight tugging) to “assist” the placenta in detaching (Note: The majority of obstetricians do this as it is part of “active management of the third stage” which is predominately and widely taught in medical schools and residency programs across the U.S.)  When the cord is cut soon after delivery, it also allows for the nurses/pediatrician to take the baby away from the mother (either in or outside of the room) and weigh it, tag it, footprint it, give it medications like vitamin K shot and erythromycin eye ointment, and swaddle it. (Note: If you think that sounds assembly line-ish, your right!  These practices are based on a desire for modern maternity hospital wards to increase their efficiency!)  Typically mothers are told “Oh this won’t take very long!  You’ll have the next 18 years to spend with your baby!  It’s too hard to hold the baby and get stitched up anyways!  We’ll give her right back…promise.”  I would like to add that it is my personal philosophy that any practice that is done solely or mainly for obstetrical convenience and not for the safety or wellbeing of the mother or baby is a practice that should be re-thought or abandoned!

 

#2  The placenta does not stop working when the baby is born.  In addition, blood continues to flow from the baby to the placenta and back again making the claim that the baby will get “too much blood” a physiological fallacy especially if the baby is placed on the mother’s abdomen skin-to-skin above the level of the placenta which assures that blood will continue to flow, but not to excess.  (Unless, of course, the cord is milked, and by that I mean the practitioner puts the cord between his thumb and forefinger and pushes all the blood in the cord into the baby and then clamps it, a practice which is both outdated and harmful in the fact that it will most surely lead to neonatal jaundice.  This old-school practice of “milking” the cord is probably where delayed cord clamping inaccurately got its bad reputation!) 

 

In my quest for more knowledge on this topic I stumbled upon a YouTube video entitled “Better Birth VA – We Can Be Much Kinder” produced by L. Janel Martin. 

 

 

This video was created in part for the Birth Matters Virginia Video Contest.  It is a fascinating video that interviews a variety of midwives/obstetricians including:

 

 

This list of birth attendants, both obstetricians and midwives, are practitioners who are in support of delayed cord cutting.  More research into their backgrounds and practice revealed to me that they all believe in, work within, and support a midwifery model of maternity care, a woman-centered model that has been proven to reduce the incidence of birth injury, trauma, and cesarean section and promote empowering, positive birth experiences for childbearing families. 

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Let’s take a moment to learn a little bit more about the research that SUPPORTS delayed cord clamping/cutting:

 

  • Delayed Umbilical Cord Clamping Boosts Iron In Infants (2006): A report of a study conducted by UC Davis nutrition professor Kathryn Dewey that revealed a two-minute delay in cord clamping at birth significantly increases a child’s iron status at 6 months of age.  This study documented for the first time that the beneficial effects of delayed cord clamping last beyond the age of 3 months.

 

  • Early versus delayed umbilical cord clamping in preterm infants (2004): A Cochrane review (considered the “gold standard” of research and evidenced based practice) of studies on babies born prematurely which revealed that delaying cord clamping for greater than 30 to 120 seconds, rather than early clamping as is the current obstetrical practice, seems to be associated with less need for transfusion, less intraventricular haemorrhage, and helped the babies adjust to their new surroundings better.

 

  • Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (2008): A Cochrane review that showed no significant difference in postpartum hemorrhage rates when early and late cord clamping were compared. The review also reported growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.  (It is important to note however that the act of placing the baby on the mother’s abdomen skin-to-skin above the level of the placenta assures that blood will continue to flow, but not to excess.)

 

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So let’s break it down shall we?!

 

The PROS of Delayed Cord Clamping/Cutting

(This list was written by Marie Berwald, a certified HypnoBirthing practitioner and Yoga instructor from Canada, for a post entitled “Late vs Early Clamping of the Umbilical Cord in Newborn Babies” on her blog Birth Bliss.  Marie supports each one of these points with research so please check her blog out!)

 

1) The blood in the placenta rightfully belongs to the baby, and babies not receiving this blood have the deal with the equivalent of a major blood loss or hemorrhage at birth.  It is estimated that early clamping deprives the baby of 54 to 160 ml of blood, which represents up to half of a baby’s total blood volume at birth.

 

2) There is a significant amount of iron in the cord blood which the baby needs for optimal health and for the prevention of anemia.

 

3) Babies benefit from the increased oxygen available to them from the cord-blood when the taking these first few breathes.  The earlier the cord is clamped, the more likely the incidents of respiratory distress.

 

4) The blood that babies receives through the cord after birth acts as a source of nourishment that protects infants against the breakdown of body protein.

 

5) As an added bonus, delayed cord clamping keeps babies in their mother’s arms, the ideal place to regulate their temperature and initiate bonding and breastfeeding.

 

The CONS of Delayed Cord Clamping/Cutting

 

1)     May increase the baby’s risk for jaundice, a condition that many newborns develop related to the baby’s immature liver that cannot process bilirubin, a yellow byproduct of the breakdown of old red blood cells.

 

It seemed to me that the PROS of delayed cord clamping outweigh the CONS however I feel that it is important to explore the subject of newborn jaundice more…that is, Is it something that parents should be worried about?  Is it serious enough to trump all of the research supported benefits of delayed cord clamping? 

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The answer to my question came from one of the obstetricians featured in the YouTube video featured above, Dr. Sarah J. Buckley.  In an article entitled, Leaving well alone: A natural approach to the third stage of labour  Dr. Buckley writes,

 

“Early clamping has been widely adopted in Western obstetrics as part of the package known as active management of the third stage. This comprises the use of an oxytocic agent- a drug that, like oxytocin, causes the uterus to contract strongly- given usually by injection into the mothers thigh as the baby is born, as well as early cord clamping, and ‘controlled cord traction’- that is, pulling on the cord to deliver the placenta as quickly as possible.

 

While the aim of active management is to reduce the risk of haemorrhage for the mother, ‘its widespread acceptance was not preceded by studies evaluating the effects of depriving neonates [newborn babies] of a significant volume of blood.’

 

Some studies have shown an increased risk of polycythemia (more red blood cells in the blood) and jaundice when the cord is clamped later. Polycythemia may be beneficial, in that more red cells means more oxygen being delivered to the tissues. The risk that polycythemia will cause the blood to become too thick (hyperviscosity syndrome), which is often used as an argument against delayed cord clamping, seems to be negligible in healthy babies.

 

Jaundice is almost certain when a baby gets his or her full quota of blood, and is caused by the breakdown of the normal excess of blood to produce bilirubin, the pigment that causes the yellow appearance of a jaundiced baby. There is, however, no evidence of adverse effects from this mild jaundice.  In fact, jaundice, which is present in almost all human infants to some extent, and which is often prolonged by breastfeeding, may be beneficial because of its powerful anti-oxidant properties.

 

Early cord clamping carries the further disadvantage of depriving the baby of the oxygen-rich placental blood that Mother Nature provides to tide the baby over until breathing is well established. In situations of extreme distress- for example, if the baby takes several minutes to breathe-this reservoir of oxygenated blood can be life saving, but, ironically, standard practice is to cut the cord immediately if resuscitation is needed.”

 

I encourage you to read the full text of Dr. Buckley’s article on her website as she not only talks more about the benefits of delayed cord clamping, but she also supports all of her arguments with research.

 

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Are you interested in delaying cord clamping during the birth of your baby?  If you are, know that the research supports you!  If your birth attendant states that she/he does not usually practice delayed cord clamping/cutting but doesn’t automatically shoot the idea down, as her/him if she would be willing to learn more about it.  On the other hand be weary of any birth attendant that discourages this practice, tries to talk you out of it, or outright refuses to participate.  This could be a red flag that she/he will not be wiling to support any other desires in your birth plan.  A regular visitor to my blog recently wrote me this email:

 

Dear NursingBirth,

 

I belong to an online birth club and a fellow mom wrote this post the other day:

 

“I met with my obstetrician yesterday for my 32 week appointment and brought my birth plan with me.  She looked over it and proceeded to tell me all these issues with it…  I want to have a natural/med-free childbirth and mentioned if the labor wasn’t progressing I would like to try nipple stimulation or breaking my water first. She told me no, this it is bad for the baby, and that pitocin is less bad for the baby.  I want to let the baby’s cord finish pulsating before cutting it… she said absolutely not, because it increases the risk for jaundice. Then at the end of the appointment she walked out and I over heard her talking to a nurse about all the issues with my birth plan and how I must have just copied and pasted stuff from the internet.  Maybe I’m being overly sensitive, but it just seemed a little harsh and awkward.  What would you guys do?”

 

Everyone has been writing back to her that she needs to consider finding another doctor but she seems reluctant because she is already 32 weeks along and has had this doctor for her entire pregnancy.  What do you think?

 

Sincerely, 

Concerned Friend

 

My thoughts….this is a RED FLAG to walk right out of that doctor’s office and never look back.  This doctor CLEARLY does NOT practice evidenced based medicine.  Is switching birth attendants during the last few weeks of pregnancy a hassle and nuisance that a mother should not have to go through on top of all the other stresses she is probably experiencing?….ABSOLUTELY!  But is it absolutely imperative that she still switch practices even though it sucks big time….YOU BET IT IS!  I hope that any mother that finds herself in a similar situation truly understands the risk of staying with a birth attendant that does not support her birth plan just because she don’t want to a) hurt anyone’s feelings, b) think she can still have the birth you want without her/his support, c) go through the hassle of finding a new attendant (trust me, I know it is a huge hassle). 

 

The bottom line for me is this:

 

IT’S YOUR BIRTH!!  YOU ARE ONLY GOING TO BE GIVING BIRTH TO THAT CHILD/CHILDREN ONCE IN YOUR WHOLE LIFE!!  YOU, NOT YOUR BIRTH ATTENDANT, ARE THE PERSON THAT IS GOING TO HAVE TO LIVE WITH THE CONSEQUENCES OF A BIRTH THAT IS CONTROLLED BY SOMEONE ELSE!!  YOU HAVE THE RIGHT TO HAVE THE POSTIVE, EMPOWERING, SAFE, AND HEALTHY BIRTH THAT YOU DESIRE!!

 

For help writing a birth plan please check out:

 

 

Don’t Let This Happen To You #23: Alona & Dmitry’s Unnecessary Repeat Cesarean Section April 29, 2009

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 5:41 PM
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Continuation of the “Injustice in Maternity Care” Series

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Me:  “Sally, she’s pushing.”

 

Sally: “What?”

 

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

 

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

 

Me: “Was she pushing 20 minutes ago?”

 

Sally: “Well no but…”

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Kate: “Dr. W wants to do a cesarean.”

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

(1)  ICAN’s Cesarean Fact Sheet

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

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

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

 

And find a local ICAN support group near you!

 

 

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

 

Must Read Blog: “It’s Your Birth Right!!” April 26, 2009

Filed under: Ideas & Information,Ramblings,Reviews & Commentary — NursingBirth @ 9:48 AM
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Stemming from a comment left on my blog, I was directed to check out a relatively new blog entitled It’s Your Birth Right!! and I have to report that this is quickly becoming one of my new favorite blogs J! 

 

Blog creator Nicole Deggins, CNM, MSN, MPH is an author, educator, childbirth enthusiast, and woman’s advocate.  She writes that the goal of her blog is “to help women and their families make INFORMED decisions about their birth experience based on HONEST/ UNBIASED information.”

 

I am most excited about two of Nicole’s posts entitled: Choose Wisely Part I & Part II.  These posts are great because they are better than any other article I have ever read about how and why families should be picky about choosing their best birth attendant.  In my opinion these posts not only give great, unbiased advice and reference variety of helpful resources, but they are also honest about the Top 4 TERRIBLE reasons for picking a birth attendant.

 

Nicole writes,

 

“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 the four categories below, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant.”

 

The four categories that Nicole is referring to are:

 

1)     “She delivered my sister/girlfriend.”  

2)     “She is my gynecologist.” 

3)     “He is the best/most popular person in area.” 

4)     “Her office is so close and convenient to my office/house.”

 

I have to “second that” to every thing that Nicole writes about in her two posts.  I too am flabbergasted at how many women spend more time researching a new car, camera, computer, appliance, or handbag purchase than they do researching their care provider or birth options.  I am also floored by many of the women I take care of that seem to have NO IDEA how their doctor or midwife actually thinks, feel, and behaves in a labor & delivery setting.  One time, and I am not exaggerating, a woman I was assigned to care for looked up at me after a particularly upsetting encounter with her attending obstetrician (he was very rough with her vaginal exam, was down right pissed off that she refused an amniotomy and an epidural, and stormed out of the room) and said, “Wow, I didn’t realize he was so pushy!  He was really rude!  I don’t know if I want him to deliver my baby!”  I was thinking to myself, “HOW in God’s name are you just figuring out now that he is an asshole?!”  (Excuse my language but this particular doctor is a high intervention, low patience physician with the stats to prove it, on top of the fact that he treats nurses like his personal empty-headed gophers…ARG!)  Turns out the only research she did to find this doctor was that her cousin went to him and was happy with his services since he agreed to induce her early because she was “sick of being pregnant” (her words, not mine).

 

Of course there is also the lying phenomenon as well and this is one area where I feel the most sympathy for my patients.  That’s right ladies…people LIE and I hope that I am not the first person to tell you that doctors and midwives are people too!!  That’s why, as Nicole writes, interviewing potential birth attendants and ASKING FOR THEIR STATISTICS is so important.  Someone I know ended up switching her birth attendant at 36 weeks along because it had turned out that he flat out lied about his experience and philosophy regarding VBACs (vaginal birth after cesarean).  For example, if you have a question about a particular intervention, say episiotomy rate, and the birth attendant you are interviewing either skirts the question or says something vague like, “I only do them when I deem necessary,” I encourage you to ask him for his STATS.  You might be surprised at how often he “deems it necessary.”  It is also important to note that you cannot make sweeping generalizations about a care provider just by their credentials, that is, not all midwives follow a midwifery model of care and not all obstetricians follow a medical model of care (although by the very nature of their education many of them do).  So it is still important to research your birth attendant even if you are planning on choosing a midwife!

 

Also, I wonder if many women do not research their care providers/birth attendants because they come from generations of women who nodded their heads, smiled, and did exactly everything their doctor told them too regarding their reproductive health.  I mean, if a woman’s mother, aunts, and grandmothers didn’t question their doctors, what influence does she have to act any differently?  The good news however is that in today’s day in age, unlike our mothers and grandmothers, we have a most wonderful thing called THE INTERNET J.  So you have no excuse!

 

But really, I am preaching to the choir here aren’t I seeing as if you are reading this blog you obviously are seeking out more information J.  Rock on!  But to all the ladies out there who might be thinking about getting pregnant or are currently pregnant who haven’t yet started to do their research, I hope at some point someone tunes you in to all of the fantastic, helpful information that’s out there J!! In my dream world, no women ever feels the need to say “If I had only known…”

 

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

Filed under: Ramblings — NursingBirth @ 9:02 AM
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I am honored, humbled, and excited to report that just a few days ago my blog had over 1,500 hits in just one day.  I was floored when I saw the number and almost choked on my Cheerios J!  When I started this blog in February I was feeling lost, frustrated, burnt out, defeated, and disempowered regarding my role in the current maternity care system in America.  The day I wrote my very first post, NursingBirth is BORN!, was only one week after I almost up and quit my job after I had witnessed a very traumatic assault and battery against a woman I was caring for as her obstetrician performed a pudendal block against her will as she and her husband were screaming for him to stop. 

 

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

 

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

 

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

 

THANK YOU!  THANK YOU!  THANK YOU!

 

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

 

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

 

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

v     Childbirth Connection’s Rights of Childbearing Women

v     BirthNetwork National’s Mission & Philosophy

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

 

My Personal and Professional Birth, Breastfeeding, and Advocacy Philosophy

 

Pregnancy, Birth, & Breastfeeding

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

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

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

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

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

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

 

The Obstetric vs. Midwifery Model of Care

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

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

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

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

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

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

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

 

Interventions & Natural Birth

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

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

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

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

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

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

 

Autonomy & Empowerment

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

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

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

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

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

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

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

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

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

 

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

 

Thanks for reading.

 

 

Birth Resources EVERY Woman Should Know About April 23, 2009

Filed under: Ideas & Information — NursingBirth @ 12:08 PM
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I was at my local ICAN (International Cesarean Awareness Network) meeting yesterday and the theme for the night was “Birth Stories.”  Although I have never had a cesarean section, attending the local ICAN meetings is, for me, a way to get together and work with other people in the birth advocacy community and meet pregnant moms who are seeking out more information regarding their birth choices.  Anyways, throughout the meeting last night I found myself often referring to different books that I have read that I feel are great resources for pregnant moms.  Everyone else seemed to jump on the bandwagon and by the end of the night, I think all the gestating members of the group had heads that were spinning with tons of different information!

 

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

 

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

 

MUST READ BOOKS:

 

*Best Childbirth Preparation Book*

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

 

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

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

 

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

            - Ina May’s Guide to Childbirth  by Ina May Gaskin

 

*Best Practical Guide to Breastfeeding*

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

 

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

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

 

 

 MUST WATCH MOVIES:

 

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

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

 

*Most Personal Documentary About Being Pregnant In America

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

 

 

MUST SEE WEBSITES:

 

* ICAN (International Cesarean Awareness Network)

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

 

* Coalition for Improving Maternity Services (CIMS)

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

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

 

* Citizens for Midwifery

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

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

 

* La Leche League International (LLLI)

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

 

* BirthNetwork National (BNN)

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

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

- BNN believes that:

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

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

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

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

           

 

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

 

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

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 11:18 PM
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Continuation of the “Injustice in Maternity Care” Series

 

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

 

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

 

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

 

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

 

Me:  “Yes.”

 

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

 

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

 

Dr. T:  “No, it was just me.”

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Risks related to amniotomy that have emergent consequences include:

1)     Umbilical cord prolapse

2)     Fetal heart rate decelerations related to umbilical cord compression

3)     Change in presenting part

 

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

 

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

 

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

 

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

 

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

 

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

 

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A quick story…

 

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

 

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

 

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

 

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

 

X/X/XXXX

2115

S: Complains of more pain, wants relief

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

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

A: Active phase labor with unsatisfactory progress

P:  Anesthesia notified for epidural

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

                                                                                              Dr. T

 

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 10:48 PM
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Continuation of the “Injustice in Maternity Care” Series

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

Let’s continue with the story…

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Jessica & Jason: “Yeah sounds good!”

 

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

 

*Sigh* 

 

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

 

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

 

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

 

 

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

 

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

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 12:26 PM
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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.    

 

 
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