Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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

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

 

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

 

 

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July 8, 2009

 

Dear NursingBirth,

 

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

 

Sincerely,

Zoey

 

 

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Dear Zoey,

 

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

 

 

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Jill from Keyboard Revolutionary recently blogged about this:

 

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

 

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

 

This leads me to my second point…

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

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

 

Okay, enough said!

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

Lastly,

 

 

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

 

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

 

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

 

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

 

 

All My Best,

NursingBirth

 

“Pit to Distress”: A Disturbing Reality July 8, 2009

Dear NursingBirth,

 

I just saw a couple of posts about “pit to distress” on Unnecessarean and Keyboard Revolutionary’s blogs. Can you comment on that as an L&D nurse?! Is the intent really to distress the baby in order to “induce” a c-section?  I’m distressed that such things may actually happen, and am holding out a little hope that it’s a misunderstanding in terms….

 

Thanks!!!

Alev

 

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Dear Alev,

 

I wish I could put your heart and mind at ease and tell you, from experience, that this type of outrageous activity (i.e. “pit to distress”) does not happen in our country’s maternity wards but unfortunately it does.  I know that it does because:

 

1) I have read and heard stories from other labor and delivery nurses who have worked with birth attendants who practice “pit to distress,”

 

2) I have read and heard stories from women (and their doulas!) who have personally experienced the consequences of “pit to distress,”

 

and, most importantly…

 

3) I personally have worked with attending obstetricians who subscribe to this philosophy. 

  

Before I start my discussion on this topic I would like to quote a blog post I wrote back in April entitled “Don’t Let This Happen To You #25 PART 2 of 2: Sarah & John’s Unnecessary Induction”.  This post is actually the first post I ever wrote for my Injustice in Maternity Care Series.  It is a TRUE story (although all identifying information has been changed to adhere to HIPPA regulations) about a first time mom who was scheduled for a completely unnecessary labor induction and the following excerpt is a good example of how “pit to distress” is ordered by physicians, EVEN IF they don’t actually write it out as an order (although some actually do!)

 

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“…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.”

  

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.  However, this is not what many physicians I work with ask you to do.   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.”

 

 

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Ladies and gentleman the account that you have just read is called “Pit to Distress” whether the pitocin order was actually written that way or not.  What Dr. F gave me was a VERBAL ORDER to increase the pitocin, regardless of contraction or fetal heart rate pattern, until I reached “max pit,” which he acknowledged would hyperstimulate her uterus.  This goes against our hospital’s policy and the physical written order that this doctor signed his name under.  However, like some other doctors I work with, none of that mattered to him.  What he wanted was for me to “crank her pit” regardless and from my experience with this doctor, at the first sign of fetal distress we would have been crashing down the hallway for a stat cesarean!

 

Hyperstimulation of the uterus (more appropriately called tachysystole) is harmful and dangerous for both mothers and babies: 

 

“If contractions are persistently more often than 5 contractions in 10 minutes, this is called “tachysystole.” Tachysystole poses a problem for the fetus because it allows very little time for re-supply of the fetus with oxygen and removal of waste products. For a normal fetus, tachysystole can usually be tolerated for a while, but if it goes on long enough, the fetus can be expected to become increasingly hypoxic and acidotic.

 

Tachysystole is most often caused by too much oxytocin stimulation. In these cases, the simplest solution is to reduce or stop the oxytocin to achieve a more normal and better tolerated labor pattern.”

Electronic Fetal Heart Monitoring” by Dr. M. J. Hughey

 

The truth, however, is that many times stopping tachysystole is not as easy as just shutting the pitocin off.  Although the plasma half-life of pitocin is about 6 minutes, it can take up to 1 hour for the effects of pitocin to completely wear off.  And for a baby in distress, one more hour in a hyperstimulated uterus is too much!  So guess what?!  The physician has two choices:

 

#1 Administer yet another drug (like terbutaline) to decrease contractions and wait and see (unlikely to happen), or

 

#2 Administer yet another drug (like terbutaline) to decrease contractions while heading to the OR for an emergency cesarean section (much more likely to happen.) 

 

Because in the end…who wants to “sit” on a compromised baby?!

 

 

What is also unsettling is that my encounter with Dr. F regarding the most appropriate administration of pitocin for that mother was downright pleasant as compared to some of the other encounters I have had with much more intimidating and hot-headed physicians.  Labor and delivery nurses all over this country (including myself) have been bullied, yelled at, cursed out, and down-right humiliated by birth attendants who want you to “keep cranking the pit” regardless of maternal contraction or fetal heart rate patterns or in general, refusing to be a part of or questioning other harmful obstetrical practices.

 

I once had an obstetrician, while in the patient’s room, call me “incompetent” in front of the patient and her entire family because I had not continuously increased the pitocin every 15 minutes until I reached “max pit” and instead, kept the pitocin at half the maximum dose because increasing it anymore caused my patient to scream and cry in pain and her uterus to contract every 1 minute without a break.  Who wants a nurse to take care of them that was just called “incompetent” by their doctor??!? 

 

Another time I had a physician (who via this program called “OBLink” can watch her patient’s monitor strips from her own home or office) call me on the phone from her house to chew me out about not having the pitocin higher.  When I explained that I had to shut the pitocin off an hour earlier and start back up at a slower rate because the baby started to have repetitive and deep variable decelerations despite position changes, IV fluid bolus, and 10 liters of oxygen via face mask, I was told that the decels “weren’t big enough” to warrant such a “drastic measure as shutting of the pitocin” and I was “wasting her time” because “at the rate [I] was going [her] patient wouldn’t deliver until after midnight.”

 

I had yet a third doctor tell me once that he wished that only the “older” nurses on the floor would take care of his patients because they aren’t “as timid” and “are not afraid to turn up the pitocin when a doctor orders them to.”  That younger nurses like me are “too idealistic” and don’t understand “how the world really works.” 

 

And yet another time I had a physician tell me that I needed to “crank the pit to make this baby prove himself either way” and that if I couldn’t do “what needed to be done” for his patient, then he would ask the charge nurse to “replace me with a nurse who could.”

 

And guess what, when I came in the next day and read the birth log, I discovered that 3 out of those 4 patients ended up with cesarean sections after I had left that night for “fetal distress.” 

 

AAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!

 

Although not one of these physicians actually wrote in black and white “Pit to Distress” and they didn’t have to; their words and actions speak to their true intentions.  These physicians are smart in the fact that they know that actually writing “pit to distress” like some practitioners do can land them with a law suit if an adverse outcome happens and they find themselves in court.  So while it is true that one’s medical record might not show “pit to distress” on the order form, it doesn’t mean that it didn’t happen to you!  What these doctors do instead are bully nurses into to doing their dirty work for them.  (And I would like to note that just like Dr. F, I have yet to encounter one physician who will actually physically put their hands on the IV pump and turn up the pitocin themselves when I refuse to do it!…..They know better!)

 

 

As a registered nurse my practice must adhere to the American Nurses Association Code of Ethics for Nurses.  Here is an excerpt:

 

“The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.  The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

 

What these practitioners don’t realize is that when they work with nurses like me (and there are many out there!!), they are working with someone who values the health and safety of women and babies (as well as their nursing license) much more than a fake cordial kiss-ass relationship with some high-and-mighty doctor!  But let me tell you, its really frigging hard to work like that!  That is, to constantly battle with practitioners who have such a different philosophy about maternity care than you do!  I mean, even the best nurses will start to doubt themselves if they are constantly being bullied and told that they “can’t cut it” or are “incompetent” if they don’t follow the status quo!  Like many other nurses, sometimes I just don’t have the energy to argue and fight.  Sometimes I have down right lied to a doctor over the phone about how high the pitocin really is (telling them it’s running at a much higher rate than it actually is).  Other times I just “forget” to turn up the pitocin for hours at a time.  One time I actually disconnected the pitocin and discretely ran it into the floor!

 

Women of this earth…TAKE BACK YOUR BIRTH!!!  We need YOUR voice!  We need you to choose caregivers that practice evidenced based medicine, and BOYCOTT ones that don’t!  We need you to HIT THEM WHERE IT HURTS….in their WALLET!!  We need you to DEMAND better care!!  We nurses, birth advocates, doulas, childbirth educators, midwives, etc. etc. can’t make change without YOU!!

 

Thank you, Thank you, THANK YOU to Jill at Keyboard Revolutionary and Jill from The Unnecessarean for their blog posts on this issue!  I second their anger, outrage, and voice for change!!!

 

Are you an L&D nurse who has ever been ordered to “pit to distress?”  Are you a mother who has ever experienced the consequences of a birth attendant who followed a “pit to distress” philosophy?    Please share your story with us!! 

 

In closing I would like to say that I am NOT anti pitocin, but like ALL labor & delivery interventions, I speak out and advocate for the appropriate, evidenced-based, and safe use of them!

 

Please check out my next post!  “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions

 

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

Continuation of the “Injustice in Maternity Care” Series

 

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

 

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

 

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

 

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

 

Me:  “Yes.”

 

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

 

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

 

Dr. T:  “No, it was just me.”

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Risks related to amniotomy that have emergent consequences include:

1)     Umbilical cord prolapse

2)     Fetal heart rate decelerations related to umbilical cord compression

3)     Change in presenting part

 

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

 

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

 

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

 

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

 

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

 

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

 

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A quick story…

 

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

 

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

 

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

 

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

 

X/X/XXXX

2115

S: Complains of more pain, wants relief

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

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

A: Active phase labor with unsatisfactory progress

P:  Anesthesia notified for epidural

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

                                                                                              Dr. T

 

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Stand And Deliver! Research Shows Upright Labor Positions Reduce Pain, Speed Birth April 15, 2009

As if we all didn’t already know this!  :)

 

Medical News Today posted a story on a new study published in the latest issue of The Cochrane Library which found that women who walk, sit, kneel or otherwise avoid lying in bed during early labor can shorten the first stage of labor by about an hour and are also 17 percent less likely to seek pain relief through epidural analgesia.  On the whole, the review examined 21 studies totaling 3,706 births.  After reviewing the research the authors’ concluded, “Women should be encouraged to take up whatever position they find most comfortable in the first stage of labour.”

 

The Cochrane Collaboration is an international organization that evaluates medical research by performing systematic reviews and drawing evidence-based conclusions about medical practice after considering both the content and quality of existing medical studies on a particular topic.

 

I would probably bet money on the fact that every savvy birth junkie or mom reading this blog already knows this J.  I just love when the research supports what midwives and mothers have instinctually known for centuries!!

 

So get up and move girl!!  Beware of any intervention that restricts your movement and, YES, this includes unnecessary and elective inductions.  This is the #1 reason women end up with all the needless and risky interventions in the first place.  The LESS unnecessary interventions the MORE you will be able to move!

 

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

Continuation of the “Injustice in Maternity Care” Series

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

Let’s continue with the story…

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Jessica & Jason: “Yeah sounds good!”

 

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

 

*Sigh* 

 

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

 

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

 

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Sarah: “I’d really rather wait.”

 

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

 

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

 

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

 

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

 

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

 

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

 

Me: “No, I have her at 10mu/min.”

 

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

 

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

 

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

 

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

 

Dr. F:  “I was being generous!”

 

Me: “So you lied…”

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

The morals to the story are this:

 

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

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

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

 

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

Introduction to the “Injustice in Maternity Care” Series

 

Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!” 

 

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

 

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

 

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

 

Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  Since I prefer countdowns instead of count ups, I decided to start at a random number.  I have no doubt I will be able to come up with 25 situations I have found myself or my patients in that could easily make the list.  (Hmmm, maybe I should start at 1000! J )

 

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

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

 

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

 

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

 

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

Plan: pitocin and early amniotomy.

 

WHAAAAAAAAAAAAAAAAAAAAAAAT?!?!

 

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

 

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

 

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

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

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

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

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

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

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

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

John: “Yes please.”

 

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

 

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

 

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

 

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

 

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

 

To be continued….

 

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

 

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

 

 
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