The BAD Labor and Delivery Nurse, and what to do about it...

Today Facebook is abuzz with the blog post by a personal friend and soon to be student of mine. She was privvy to a VERY inappropriate conversation on Facebook that was also very public between an OBGYN and a nurse working in the same facility. To protect her privacy, I will simply post the text of her post here:

So-called compassion for c-sections from L&D doctors and nurses?

On Facebook, I have one particular friend from grade school who happens to be an OBGYN. Last night, she posts this status update (name removed for obvious reasons):

OBGYN - Waiting on a delivery.... Baby please come soon. I'm getting tired. 10 hours ago via Facebook for iPhone ·
To which her friend, a labor and delivery nurse responds:
NURSE - Ahh just cut her. Fuk it!
10 hours ago

I was infuriated to say the least and sickened to my stomach. I honestly felt like I was going to throw up. I couldn't sit there and let it go:

ME - wow NURSE - that's about the most insensitive thing i've ever heard in my life.
9 hours ago ·
ME - and this is coming from someone who had a doctor cut her baby out of her, never followed up on her care, didn't know her baby was transfered to another hospital in critical condition, left her with a festering infection for two months and could care less that i was stuck to a wound vac for another month after that. so yeah, just "cut her" sounds like really great advice.

8 hours ago · If you think any of that was enough to make you toss your cookies, these are the responses I woke up to this morning:

OBGYN - NURSE is an amazing labor and delivery nurse..., who knows me well and knows that I don't do inappropriate sections. I'm sure she was joking.
8 hours ago

NURSE - Relax MOTHER all that wasn't necessary. I am sorry u had such a bad experience for such a joyful moment. And thank you OBGYN I truely love my job and I know how to relax and joke! Hope the delivery went a bit quicker and MOTHER I hope you found a new doc....try dr ####!!
5 hours ago

ME - Out of curiosity - I wonder what the mother of that delivery would have to say to you if she saw what you wrote...what do you think her reaction would be?
about an hour ago ·

NURSE - im sure she would have a laugh with me instead of being so uptight like certain people on facebook. The problem with patients is they try to control their own deliveres so much for example "birth plans" that they set themselves up for failure. Than they dont actually look into their doctors history they just randomly pick an OB and thats how things go so terribly wrong. Patients need to have a true advocate if they feel they cant do it for themselves. So its always nice to not treat ur nurse like shit and she can be your advocate.
40 minutes ago

I'm still debating what route to take next. With the skyrocketing Cesarean rate in this country, and people finally looking at those numbers - calling it unacceptable - I'm still shocked that two "professionals" would retort in such an ignorant manner. I am 100 percent open for suggestions on this one.

---
To begin, this may have been a VERY callous and in poor taste joke between two overworked birth workers. The hospital environment is a hard working and exhaustive one, and I don't think anyone would believe that having a family and being up all night delivering babies is easy. I would like to state for the record, that I do not indulge in 'doctor bashing', or 'nurse bashing', and that I do try very hard in all of my classes and exploits to show consumers what birth looks like from the other side. Each side/perspective of birth has it's own share of pressures, inequalities, and points to consider. I always seek to understand the differences facing each side of a birthing issue, and try to bridge that gap. I spend a lot of time in my classes explaining how birth works for the hospital worker, as well as the added pressures faced by OB professionals and Midwives that people may not be aware of. This awareness creates understanding and sensitivity, and can make all the difference in the feeling and function of the 'team' at a birth.

So all of that out of the way, what this nurse said online is heinous. It's irresponsible, it's insensitive, it's rude, and worst of all, it's ignorant. It's ignorant of what kind of ramifications a surgical birth can have on a mother and family. It's ludicrous that a birth nurse could be so naive to these things, especially with all the news in the last month about cesarean. First, there was the NIH VBAC conference, which called into scrutiny womens' lack of access to VBAC births, and noted that repeat and initial cesarean rates were too high. And just this week the CDC released the 2007 statistics on the American cesarean rate, and it's at an all-time, all-world high. I won't be surprised if this bumps us from 28th in world rankings for maternal and fetal outcomes to dead last, so it's not an insignificant piece of news. A piece of news you would expect a birth worker like her to have heard about.

Clearly, there is a problem in our country, that this nurse doesn't see to understand, but more than that, she seems to be unaware of the massive efforts to change the problem, and even the current events on the subject. Add to this, that she seems UNCARING about the problems our country face, which can only be addressed one birth at a time. This is regrettable, to say the least.

It is repugnant that someone would be so unthinking to post an exchange like this in a public place, and with the attention this is getting, I sincerely hope her administrators are made aware of it and some sensitivity training and cesarean prevention education is put in place for not just her, but her entire workplace, as attitudes like this tend to fester in overworked and overstressed work environments.

Another point I'd like to make is her commentary on consumerism in birth and birth plans. We've all heard the rumors that nurses 'don't like them'. I have my students write their 'birth preference lists' very carefully, taking care to say things like, 'I trust your judgment, and these are my wishes in the event of an uncomplicated labor/delivery'. This nurse's experience is right in saying that women need to choose their providers more carefully if they want certain things to happen or not happen at their birth. Our biggest assurance for the birth of our choice is the questions we ask and the provider we choose.

However, many people stick with their teenage ob/gyn and don't look into their options, or choices. Women DO need to get educated and make better choices. This is our responsibility for our own health and our own experience. And again, this is something I cover extensively in my classes. HOWEVER.... this nurse seems t o go astray of reality when she starts assuming that women write birth plans as a mechanism to control their births because they do not have a supportive provider. This is where her personal prejudice takes over, and this is unfair to all the women under her care who do their homework.

To make the assumption that anyone with a birth plan is a 'control freak' a 'difficult patient', or 'bound for a cesarean' is a personal prejudice that does exist that I'm not sure what to do about. This nurse talks about parents needing an advocate in the birth process, and I agree. They need a DOULA, someone whose role is nearly the definition of what she is describing. But when this nurse suggests that a woman's advocate should be her nurse, I must say that I thoroughly disagree, and I do so with the utmost respect to nurses.

I have worked with some WONDERFUL women , and not every nurse is guilty of these kind of personal prejudices-- in fact, I think and I hope that most aren't. To rely only on the advocacy of your nurse, who will be working with several other patients and doctors, and whom you will meet only after labor has begun, and whom you know nothing about is not a good idea. A doula, on the other hand, will meet with you and offer support and education from early in pregnancy, and offer a continuity of care and personal attention throughout your labor that a hospital nurse cannot. You can get to know your doula and choose someone who 'click' well with your personality-- but the nurse you get is luck of the draw, so personal prejudices and opinions about birth won't be discovered until labor is in full swing, which is not the time to realize you're lacking support from the only source you planned on.

I also want to address the idea that is expressed by this nurse that women need a 'buffer' between themselves and their care provider. The sentiment here is that it's 'us vs them', which I could not disagree with more sharply. I emphasize choice and consumerism to my clients and students, and together we construct a personalized birth team based upon their wishes, goals, and specific medical concerns. The idea of advocacy in birth is wonderful, as labor does put a woman in a vulnerable place. For the laboring woman and her partner to feel 'safe', having the continuous presence of a doula who acts as an emotional support, an educational resource, and another pair of hands is only natural. But some women don't feel threatened when they are vulnerable, and some partners are well equipped to care for their laboring mothers. Educated consumers will have a provider who is aware of their wishes, and on bo ard with their goals. They will have assembled a birth team that is supportive and loving and of the same mindset, and they won't need to be protected from the 'snipping scizzors' that this nurse perceives to be always at the ready. It's also important to note that the most supportive nurse in the world cannot sway the decision of the medical care provider, or 'protect' the laboring family from intervention if its the opinion of the caregiver that it is needed.

I love nurses, and I really don't want this to be a tirade on nurses, even this particular nurse, who is largely guilty of misinformation and insensitivity. I teach my students and clients to befriend their nurses, and write down their names so they can ask for them with the next birth. I do believe that being nice to your nurse WILL give a better birth, and in many ways, the nurses are the gatekeepers and keyholders to smoother and kinder birthing experiences. But I think it's a real shame that there are nurses out there like this one, whose view point is so skewed that even on her best day, the care she provides will have an undertone of intolerance and impatience for 'that certain type' of patient who writes up a birth plan, even in the most respectful of ways.

I try to foster good relationships with the nurse s I work with so that we will remember one another and have a bond to build from with each birth we work together. We are both birth workers, there for mess and glory of birth. We are both away from out families for nights at a time, and we are both there to support a woman through a challenge that will stretch and shape her into a new kind of woman-- a mother. We should be working together. We are not so different, and this is why I am so upset by what I have read from this nurse's point o f view.

This whole issue is not new, but rather a barometer for an existing problem. This is not a setback, but an opportunity to raise awareness, push for education, and to think about our own prejudices about the birth workers we stand next to when we work. I would like to see some media coverage on this, as well as something done at the administrative level of hospitals to curb this kind of finger pointing an d negativity.

Let us seize this opportunity to ask for change. Let us use this moment to become better, ourselves. Let us turn a very ugly exchange int o a better experience for women to come. Please pass this on, and please consider your own personal prejudice and how it may be devaluing the experiences of the laboring women you serve.

Patience, patience, patients...

I was at a birth that was over 30 hours this week, and WHEW it was hard work for all of us-- obviously less for me than the laboring mother, but you get the idea. I just wanted to say KUDOS to those women who carefully choose their providers, and THANK YOU to those providers with enough confidence in 'normal' birth to not mess with things.

This was for my 'anonymous' mom who switched to my FAVE midwives at 35 weeks. What a brave, but sensationally brilliant move. I know a lot is said about how offices are supportive (or unsupportive) of VBAC moms, but I want to point out that AVOIDING cesarean should be applauded, as well. And this was certainly done.

They exhibited NOTHING but patience, despite the midwife being well into her third trimester herself, and despite an all hands on deck showing by the staff in the office, I really really fell strongly that she got the BEST care possible, and a beautiful vaginal birth.

I learned from one of these midwives that last week they let a different mother push for 6 hours. SIX HOURS-- she obviously had an epidural, but the point here is that most people would have cited 'failure to progress' or CPD and sent her to the OR after 2 or 3 hours. But baby looked fine, and this office let her go for 6. God bless Midwives. I know where I am having my next baby!

The Doula's Ripple Effect

Recently, I blogged about the importance of finding the right provider, and how that's not always easy. This is made more difficult if your needs change, or if you overlook a small detail in your discussions, only to learn late in your third tri that your one missed point is a deal breaker with a doctor or CNM you thought you loved. This is very stressful position to be in, when moms are often 'nesting' and needing to know they are in good hands, and all is ready.

I recently helped a client in this particular situation get a new office whom she and DH are VERY happy with, and now things are smooth as silk again. There was a one question deal-breaker, that was somehow overlooked, and when it came to light, we were 33 weeks or so, and not happy. I am pleased, though, that she stood her ground, and found someone who could offer her more, because I know it will make her birth day much better. Well, this mom emailed me again this week to let me know that her late term switch inspired her friend to do the same.

This friend of hers walked into her OBs office with a 'birth plan' or something like it, and the doctor refused to even look at it. He then went ON about how OFFENDED (yes, actually offended) he was that she would bring something like this in to him. He has been delivering babies for (blah blah blah), and what does she know about it as a first time mom? How DARE she question 'his majesty'. Thankfully, this woman had a very level head, and said, 'thanks but no thanks', and walked.

She is now on the search for her new obstetrical mr. or mrs. right, and has told my client that her last minute search's success gave her the strength to stand up for what she believed in and get more for herself.

Now it upsets me to the Nth degree that there are ACTUALLY medical professionals out there who behave this way. God Complex, much? Since when is informed consent a frivolity, and since when does a woman not have a right to ask questions and make requests about what's done to her body when she's in labor?? Those outdated people who see birth as 'frought with danger... but we have the technology to save you from these perils', and who see it as a 'medical procedure' and not a life-changing, spiritual, beautiful right of passage, well, they make me ill. But all we can do is say NO, and go to someone who will respect us.

We need to be educated consumers, and to vote with our dollar.... and it is my hope that more and more women will do this, after hearing stories like my clients', and being encouraged by their doulas and other support professionals, that these outdated control freaks will soon step aside-- forced into early retirement due to public pressure for an open-minded, respectful physician.

I take this as a good sign-- that someone I don't even know is going to get the birth she wants because of encouragement I gave to someone else. So while this is a job that comes with many frustrations, it's important to take moments like this revel in the ripple effects your empowerment has on the community you live in. Personally, I couldn't be happier with my small role in the outcomes for these two women. And it has me pumped up to keep going, and to change the world a bit more each time!

Go Doula!!! Go Women!!! Go Birth!!!


RAH! RAH! RAH!
I hope the sidelines are always this powerful!

Interviewing a birth provider, and making the tough calls.

Recently I have had to help a client get a new provider four weeks shy of her due date, and also had a friend who is trying to conceive talk to me about options for birth providers. This got me thinking. I have this HUGE three page list of questions I give to people to give them a general idea of what ask and why, but it's too cumbersome, and too detail oriented... I thought, there has to be a way to make this simpler....

So I came up with this.

1. How can help me to achieve the kind of birth I am looking for (un-medicated, intervention-free, etc)

This question is open ended enough that you can hopefully gauge their REAL opinion on what you're hoping to do, as well as their level of comfort talking off the cuff about the topic. Stammers, and side topics are a good indication the doc you're looking at doesn't know much about it, or doesn't do it much.

2. How do you feel about doulas?

Now, obviously, I think everyone would benefit from a doula. But that's not the point of this question. Some doctors don't like doulas, and I have found that those doctors are the ones with high rates of intervention and cesarean rates. Not to mention that closed-mindedness is not helpful when it comes to healthcare providers! Some people may have had a bad experience with a doula, just like doulas sometimes have bad experiences with doctors-- the goal here is not to judge by those terms, but to gauge open-mindedness, and intervention rates.

Many doctors who straddle 'the line' of medical/natural have told clients of mine things like, 'well if that's the kind of birth you want, you would definitely be better off with a doula'. Meaning, if you're calm and under control and I don't have to worry about you, you can do whatever you want. But if you're NOT, then I just might throw the book at you. And this is not necessarily a bad thing, but can be a point of concern and warrant more questions on your part.

3. What is your cesarean section rate?

The US average (mind you we're 37th in the world when it comes to maternal and infant mortality, which is ABYSMAL) for cesarean sections is 31.8%. The World Health Organization states that there is no reason the number should be above 10-15%. Don't rest until you get the real number! They have it, or they can get it.

This can also be a good spot to segue and ask if they accept VBAC births. Even if you're not a VBAC, the answer to this question says a lot about the open-mindedness of the clinic, as well how much power the legal department has over the medical decision making.

4. What is your epidural/narcotic usage rates?

Some places give a combined stat, and some keep them separate. Either way, if it's over 60 or 70%, it's not LIKELY that the provider has seen the ebb and flow of many un-medicated deliveries, and may overreact to a situation that is normal, but 'could' be abnormal. Only someone who sees a large number of natural births will be able to adequately monitor support and gauge a mother who is un-medicated. This is where the science and the practice of medicine seem to really split. They learned about normal birth in college (theoretically), but may have not attended enough of them to be comfortable with them. Practice makes perfect-- find a practice who regularly supports natural birth, and you'll be in much better hands!

Also keep in mind that you need to have some symbiosis with ALL the providers in the group, because if you end up with the one OB who does not support the birth you are looking for, that can be a problem. Though, having been in this situation once, we did got mom through an all natural, un-medicated delivery without so much of an IV (which he was not happy about), but afterward he told us that was his first natural birth, and he was very impressed and learned a lot. So who knows... maybe we converted him. :)

Next, you need to ask about their office/hospital policies on the following things:

1. monitoring.

What kind and how often? All the studies show that too much monitoring can be really detrimental to the process of natural birth, so we like intermittent, external monitoring, or even doptone. And 'intermittent' can mean different things to different people, so be sure to ask what that entails for them. Another great question is if they have telemetry units. These report the results on radio waves, and therefore, have no cords. They can also be used underwater and in the shower. Not many places have them, but those that do are worth searching out.

Clearly, if the situation warrants a closer look, you can change your 'wish list' on monitoring, but if your office has a standard 'break the bag and insert the internal fetal monitor' policy, you may want to run screaming.

2. IV/hep lock usage

Is an IV standard? Is it possible to used a saline/heparin lock instead? Many doctors express concern over the skipping of he IV, and I can understand why. Many of the medications needed for emergency situations kept on the floor are meant to be administered directly through an IV-- so if you injected it, it could be all kinds of horrible for you, and probably wouldn't work either. So, there is a safety risk for women without IVs in unexpected situations, HOWEVER, there is no reason that a heparin lock IV start/access point isn't good enough. they can hang the saline, and literally have you connected and medicated with only a few extra moments. For most women, those extra moments are not critical, and the freedom of movement gained from not being tied to a pole, and going pee all the time is invaluable.

3. pushing positions

If they tell you supine with your legs up is best, run screaming. This has been proven time and time again to be THE WORST delivery position possible-- though, doc can see much better this way.

While many women do prefer to climb into bed to deliver, there are many options for positions even while in the bed that can help the mother use gravity, and help her use her body for leverage. Not having a choice here dictates that the doctor has not delivered in other positions often enough, and I wouldn't want to be their first case out of their comfort zone!

4. what kind of 'clock' can I expect to be put on?

Do I have 24 hours from when my water breaks until baby NEEDS to be born? 48?? In other countries women go days, and sometimes even weeks with broken waters before active labor sets in. It is not necessarily harmful at all, however, the legal-political climate in this country allows little room for situations like this. If your labor isn't 'fast enough' to beat the clock, you will be looking at pitocin at the least, and a cesarean at the most. So, the answer to this question is quite important.

5. food and drink in labor

The ACOG has recently come out in favor of food and drink in labor. A mother's blood sugar needs to be able to keep up with the marathon events happening, and allowing no food or juice is very detrimental to that process. There is really no reason to keep a mother from doing what comes natural, especially if she is hungry!

6. What are your 'standing orders'?

Standing orders are what doctors have on file at the hospital to do to get every patient ready for laboring. It often includes blood work, some monitoring, an IV, and in many cases, AROM, an internal exam, and pitocin. These orders are going to tell you a lot about how they practice, and how much patience they have for longer labors.

And lastly, ask WHY a lot, and use your gut! If you get a funny feeling, stick with it, and interview some other people. And remember-- charisma and charm are for getting the baby in there, they don't help get the baby out! Some doctors are very personable in the office, and turn out to be abrasive, short, or different in the hospital, so knowing their policies will tell you a lot about what you can expect when 'the going gets rough'.

I hope this list is helpful-- and remember to choose wisely!

Preparation for the big day (at war)

There have been some intense conversations going on on Facebook the last few days about the sign put up by one doctor’s office in Colorado. I am not going to address the sign exactly, other than to say ‘Thanks for letting me know so soon, so I can get a provider who has my best interests in mind’.

What I am going to talk about here, is doing your homework, and preparing yourself so that 1. You don’t have an unsupportive provider like this one, and 2. You can deal with him if the event of a last minute substitution at the hospital.

Unfortunately, there is quite a chasm in the world of maternity care, with natural childbirth acting as the polarizing factor. This includes the heated debates on the cesarean epidemic, policies on VBAC deliveries, doula care, labor medications, and much more. It seems there are thousand points to disagree on, and none that we can all say ‘okay, I can meet halfway on this one’.

In my debates over this sign, it was gently inferred by a fellow birth activist that perhaps my inexperience with all things ugly in the delivery room was the reason I was not up in arms, and that perhaps with time, I would change, and become more angry and jaded. Now, I am not taking words out of her mouth, here, nor am I going to tell you her name—but this is the impression that I got from our chatting.

I suppose to some, I am an inexperienced doula. With less than 20 births, and not one cesarean, one could assume I have had nothing but great births, but this is simply not the case. I have seen all sorts of things that have upset me to my core, sent me home crying, and swore me off my profession. It’s not always an easy job. But regardless of this, I believe the reason I can remain optimistic when birth has become such a battlefield has to do with the classes I teach, and the way I prepare my students and clients so that their births CAN be beautiful.

My birth classes are intense. I am a certified Bradley Method instructor, and I teach a pretty hard line on reality. Many of the births I attend have been my students (or come from other Bradley instructors), and therefore, they chose the right birth professional, made the right decisions, and did not allow themselves to fall victim to a terribly flawed system. Some doulas I know with 50+ births can’t do this. So I say the claim that experience makes your eyes more open, or makes you more aware of the problems at hand and what to do about them, is not a valid one.

Birth is not something that happens to my students, it is something they learn to embrace. The births I have been to have not all gone perfectly, in fact, some have gone horribly wrong. But my students are able to make good choices no matter what hand they are dealt, and are able to communicate well with their birth team, and feel confident that THEY have a choice. This said, I know many women do not have choices, and have been on a large handful of volunteer births that illustrated this for me in way that is more visceral than I can explain to you.

The system is flawed, and it seems that some of us are at war. My classes empower my students to make good choices, and not become victims in this war. The importance of being an educated consumer has never been greater, and you can’t be an educated consumer without an education. So find the BEST class you can in your area, and if you’re like me, take two. Learn about red flags, possible interventions, cesarean rates, and your provider’s comfort level. Don’t let this battle be fought in your uterus. And with my classes and me as a doula by your side, there’s very little chance this will happen to you. We may be at war, but this does not mean we can’t find peace on our big day.

Breastfeeding Tea

I just learned that there is a Dr. Mary Ann Meyer-Jones in Valparaiso, IN who hosts a FREE Breastfeeding 'Tea meeting' for moms who are her patients once a month.

How cool is that? Wish more offices offered this as well!

(PS-- if you are a provider, I volunteer to lead the meetings)

I am filing this away under 'cool things to start up in the future!'

Article on laboring womens' rights

Is a woman in labor a person? Legally?

This article really shook me. I cannot believe that something like this could even happen. It is so upsetting that a woman's rights over her own body could be superceded by anyone, let alone her physician.

This is just another reason to make sure you have chosen a like-minded provider who understands and respects your wishes. Granted, this will not ensure the labor and delivery of your choosing~ there are too many variables (the largest of which is mother nature) while woman and child work through this stressful but momentous event. It is not clear in the article whether the mother did endanger herself or her child by refusing a C-section, but what is clear is that there was a healthy outcome.

The idea of 'safety' is a relative one, especially when it comes to something as random and up for interpretation as medical testing and procedures. Truly, labor and delivery is more of an art than a science, and I wish that there were some philosophy in there as well. Sadly, the philosophy of medicine in Obstetrics has been replaced by legality, and attorneys. But regardless, whether is was 'safe' for this mother to deliver vaginally is not the issue here, the issue is that no two people have the same idea of what 'safe' means. To some, nothing is more safe than a C section, and to some, nothing is more safe than the natural process of labor. Most of us fall in the middle somewhere, and there is no 'right' answer. We all have to answer to the forces of our environment, be they our malpractice insurance, the hospital, our bodies, or our hopes and dreams for a beautiful baby and a beautiful birth.

Once again, I urge you all to try to understand where the other 'team' is coming from, and instead of becoming more polarized and combative, try to meet in the middle. Perhaps if the 'natural' and 'medical' camps spent energy on this instead of fighting against the other side, sad cases like this would not have to happen.

Consumerism in medicine has never been as important as it is now~ so choose your birth team and facility wisely, and let the almighty dollar cast it's vote on what kind of care will succeed in the end. Choose wisely for yourself, your friends, and your daughter, so we may hope to have a better system in place sometime soon.