Nursing Birth

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 37^th 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.    

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 )

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

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!