My Dears K, N, A, and T....
I love you guys...you know I do. I can't thank you enough for being there when I get saturated with medically managed, high risk births, and you spend entire afternoons with me reminding me "how it's done" when things are blissfully normal, helping me regain my perspective; but sadly, things are not always normal, even during some of the births you attend, and you have to transfer.
I was so pleased that you had found an M.D. to back you up....not an easy (heck, pretty much impossible) thing to do in this overly conservative area; but now that backup is being taken away.
And why?
Now, I'm getting this information second hand (it might even be third hand), but I trust the source I got it from implicitly, although I'm allowing for a margin of error in the sending vs. receiving of the communication that it took to trickle down to me; but it seems that Dr. H.'s partners are frustrated that their decisions were being second guessed when you would arrive the hospital with your client, and they were on call instead of him. An example that was given to me went something like this; when the Docs expected continuous monitoring, they got comments like "But Dr. H. says we don't have to have that"...and similar stories.
Oh my treasured friends! You know better than this! As incredibly knowledgeable and skilled as you are, once you and your client decide to transfer, you are no longer on your own turf. By definition, the pregnancy of the woman you are caring for has now become high (well, at least higher) risk, which takes you out of the care provider position, and places you into the support position. I know I'm not telling you anything new; but perhaps because Dr.H. has been so easy going and laid back when you came in, you assumed that his partners would be as well.
Not so. In my albeit distant and limited experience with all three of these physicians, they each have their own style of managing their patients. As with any practice, if a woman in labor comes in and her own physician is not the one on call, some compromises are going to have to be made if the other physician has not been consulted on the birth plans. At the very least there is going to have to be, if there is the time for it, some gentle discussion of whether or not she is comfortable providing care the way you assumed Dr. H. would. Keep in mind that you can't really be certain what decision's Dr. H. might have made...depending on the reason for your transfer, he might have insisted on continuous monitoring as well.
I can't speak for any of these physicians, any more than I can speak for any of you; and although I am well aware that our area is full of intervention-happy Docs who would just as soon have you prosecuted as look at you, I don't believe that every doctor out there is out to deny a pregnant or laboring woman her right to make well-informed decisions about her own body, her own baby, and her own birthing; but I do believe that every doctor has a right to practice in a way in which he or she is most comfortable...in a way that does not compromise their values, and that protects them from a lawsuit that could jeopardize their license, their practice, their family, and their employees and their families.
This is only fair.
If we want the medical community to respect us as collaborators, then we have to collaborate. We would not want them coming into a client's home and insisting on lithotomy position for the birth, or forbidding any food or drink in labor; in kind, we should not be insisting that they practice in a way that compromises their comfort level when a client is transferred into their care. Some compromises are going to have to be made, and the client needs to be made aware of this.
I know that, once a client is transferred, you feel very protective of her...that you want to advocate for her; but in truth, the legalities in this situation are that only a client (or her family) can advocate for herself. The fact that a transfer has taken place, in and of itself, is a clear indication that the client's hopes and expectations for her birth are not going to be completely met. It's a sad reality that we can't always have what we want, no matter how hard we try. Remember that old adage...how do you make God (the Universe, etc.) laugh? Plan something.
Life is unpredictable; the beginning life, as you all have experienced over and over, is equally unpredictable. Given the love and support of her treasured midwives, a client encountering a disappointment in her birth experience can be helped to feel the joy and beauty of her baby's birth, no matter how that birth is accomplished. True, the personnel of the hospital you transfer to may not be as supportive as we would like them to be; but that comes as no surprise to any of us; we know what kind of environment you are likely to encounter once the decision to transfer is made. Of course things could be done better than they are currently being done...but we aren't going to be able to achieve change with the one birth that is currently in question. It will take dozens and dozens of delicately handled transfers for the medical community at large to even begin to trust, respect, and cooperate with you. It's just the unfortunate reality that we have to accept right now.
Maybe it's not too late. This was a wonderful opportunity for collaboration; given Dr. H.'s respect in the community at large, once it became known that he was willing to back you up, maybe others would be willing to open their minds to the possibility (although I remember the situation with Dr.S. from years ago, and my hope is diminished somewhat). Maybe a well-written letter of apology and compromise, along with a request to meet and discuss the situation might change things for the better.
I can hope, can't I?
Blessings and Love,
K.
Saturday, July 26, 2008
Tuesday, July 22, 2008
And Now for a Word from Our Sponsor...
From reading other blogs of L&D nurses, I’ve begun to realize that things are pretty much the same all over the country. So, instead of attempting to rewrite what has already so elegantly been done, I now turn this blog over to my online friend at At Your Cervix… L&D nurse extraordinaire, future midwife, and all around “Good-ole-girl”. These are her words…I could only hope to be able to so clearly depict the realities of this “Love it, but Hate it” job
“Which leads me to some of my gripes and concerns about coming to L&D triage.
- Don't ask for food immediately - it's not happening - think about it - you're here
- because of pain, leaking fluid, vaginal bleeding, preterm labor, n/v/d, or for whatever reason. You will NOT be automatically given food upon arrival, and chances are good you won't get food while you're here on L&D. The best you can hope for is some clear liquids, unless your doctor allows you to eat. And if you can eat, chances are you don't need the level of care required on L&D. (Ed. Note…and no, we can’t provide a meal to your mother, your boyfriend, or your kids…I’m sorry they are hungry and you didn’t have time to feed them. I’m hungry because there are six more women here just like you, a dozen more sitting in the waiting room, we’re understaffed, and none of us in L&D are going to get a meal break tonight.)
- Triage means: you will be evaluated, and seen according to severity. Your stomach virus is a lower priority than the preterm patient who is ruptured.
- If you're not in active labor, expect to be sent home. Home is more comfortable than a small stretcher in a room with 4 other women who are also being triaged.
- I'm not here to cater to your every whim. I am caring for multiple women, with multiple problems. I have to prioritize, so do not be upset if I can't get you that cup of water immediately. There is only one nurse in triage. I cannot be everywhere.
- There are no TV's in triage on purpose - to discourage you from staying any longer than needed. Plus, I also need to be able to hear all 5 EFM monitors simultaneously. I cannot do that with 5 TV's blaring at full volume.
- Each person may have ONE visitor with them. The triage bays are too small to accommodate your entire family.
- Speaking of which, just WHY did your friend/family member drag your 1 yr old child out to the hospital at 10pm? (ed. Note…or 2:00 A.M., tired, fussy, hungry?)
- I really don't care about how tired you are of being pregnant when you're 32 weeks along. You won't be admitted and induced because of this. In fact, you're here because we're trying to STOP your preterm labor. You really want a baby subjected to being in the NICU for weeks?
- If you can't urinate on your own for the urine sample I need from you, I can easily use a catheter. But you don't really want that, right? Because I don't want to have to catheterize you unless I absolutely need to. It hurts too much. So please drink the fluids I've given you to help you produce urine for the specimen.
- I'm glad you have signed your tubal ligation papers, but I'm not worried about that right now.
- I'm going to keep my mouth shut when this is baby #4, and you're only 21. And the father of this current baby wants 10 more babies, because "they're so cute." And he doesn't work. Neither do you. Great.
- I'm also going to keep my mouth shut when you presented to prenatal care only 1 week ago at 38 weeks, and you're in active labor today. Oh yeah, and you have 3 different STD's to boot. And the baby has a cardiac defect. And this was NOT your first pregnancy, so you knew better. But I will keep my mouth shut, even when I want to lecture you about good, early prenatal care.
- Don't expect an epidural upon arrival - when your cervix is closed/thick/high, and your contractions are every 20 minutes. You're going home, because you're not in labor!
- Please don't bring in your suitcase when you are the above patient. You're just going to have to lug it back to the car when you leave. Besides, it also takes up precious room in triage, and I need to be able to get to the fetal monitor to care for you and your baby. (Ed. Note…ditto the car seat…your not-yet-born baby’s car seat belongs, duh, IN THE CAR!!!!!!!!!!!!!!!!
- Thank you for bearing with me when I've made you wait for that drink of water. I appreciate the "thank you" that you gave me when I was finally able to get it for you. I apologize for it taking so long.
- Thank you for not arguing with both your doctor and then myself, when your doctor has discharged you home. Thank you for realizing that you don't need to be admitted today.
- Thank you for listening intently to my discharge instructions, and asking intelligent questions to clarify any concerns. This shows that you are actively listening to my teaching.”
- (Ed. Note…and thank you for looking at me with suspicion every time I make a request, perform a treatment, relay information to you from the doctor…I really am here to help you. If you distrust us so much, why are you here? We’re not the only L&D in town…
- Ed. Note continued…yeah, yeah, I know, you’re gonna sue _________Hospital, because they were so stupid as to tell you that you are not in labor…guess you’re gonna have to add us to that claim, because YOU’RE NOT IN LABOR!!! Fine, drive on over to ________ Hospital, five miles further up the road…they’re going to tell you the same thing…and I just LOVE knowing my tax dollars are paying for your waste of hospital resources for absolutely nothing! By the way…don’t you have better things to be doing at 3:00 A.M. in the middle of the week than shopping for some hospital that will admit you because you are “tired of being pregnant”?...like, perhaps, SLEEP?)
- Ed. Note, continued, one last time…for one of my personal favorites…
L&D RN…”When did your vaginal bleeding start?”
Answer…”About an hour ago”.
L&D RN…”Did you soak more than one menstrual pad?”
Answer...”Uhm…I didn’t use a pad…but there’s this spot on my underwear…
[L&D RN squints to see the pin-sized, pink dot on pts underwear, which patient happily whips off and holds up in the air].
L&D RN “When did you have sex last?”
Answer (giggling, looking up at snickering boyfriend…”About an hour ago”.
Here, another gem from At Your Cervix (catchy blog name, isn’t it? Wish I had thought of it, but that’s just how clever this writer is).
She arrived via ambulance. 18 years old, pregnant with her first baby. This was by far not her first visit with us, nor was it the first time she utilized the ambulance service to grace us with her presence.
"What brings you to L&D tonight?" I ask her, my standard opening line.
"My water broke."
Hmm, ok. I do my usual assessment and evaluation. Chief complaint of large gush of fluid x 1 at 3pm. Not wearing a pad on arrival, nor is she currently leaking any fluid. She's also smiling. Started having "contractions" while in the ambulance on the way here, now rating them 5 out of 5 on the pain scale.
(You haven't felt pain at a 5 out of 5 yet honey, I think to myself. Note that she's still smiling.)
She also mentions to me that the doctor in the clinic "broke my membranes" today. Hmm, at 9am, the time of her appointment? And she's just now coming in with c/o ruptured membranes at 3pm? I don't think so.
I try to clarify things with her a bit, "The doctor today must have stripped your membranes in the clinic, because she would have never broken your membranes on purpose in the clinic - it's just never done that way. Also, if she broke your membranes, it would have been accidentally, and she would have sent you over to us on L&D immediately for monitoring."
But no, she insists that the doc "broke my membranes" in the clinic at 9am, then then her "water broke" at 3pm. We're not talking about the highest on the genetic chain of life here, if you get my drift.
"So, why did you call an ambulance?" I question her.
Her mother answers, "well, we couldn't find anyone to drive her here. And besides, her insurance pays for the ambulance." I note "medicaid" under her insurance company in her demographics paperwork.
I try REALLY HARD to bite my tongue.
When later letting her doctor know that she's arrived, her doc even mentioned that the doc the patient saw in the clinic that day told the patient POINT BLANK - DO NOT CALL AN AMBULANCE, call for a taxi if you can't get a ride in to the hospital.
Oh yeah, and the doc stripped her membranes in the clinic that morning. For which, I wanted to verbally lash said doc, because this patient was only 37 weeks gestation.
In the end, the patient's membranes were intact, and she was sent home - without the luxury of a taxi - I mean an ambulance - to bring her home.
+++
Comments re: taxi/ambulance service abuse
Recently, in the comments section regarding use and abuse of the "taxi" aka ambulance services, there was this comment:
Thea said...
"What, no room at the inn tonight? It's sad when someone's career slowly strips them of compassion. Have you ever tried to get around without a car for any decent amount of time? Do you know what it's like, truthfully? Have you been 18 and pregnant? Do you have a clue?"
And here is my response:
"Thea - actually, I do know what it's like to be pregnant as a teen - twice. I had my first child at age 15, and my second at age 18. I wasn't bashing her for being pregnant as a teen, because I've been there myself twice. I was, however, upset - and rightfully so - that young women like herself will abuse the ambulance and hospital services like this. I had yet another ambulance abuser come in last night at work. It happens almost every single day! They don't care, because their "insurance" pays for it - well who pays for that? We do - the working class.
I have also been on state aid - for my pregnancy at age 18, only because my then husband did not have health insurance at his job. I knew the importance of prenatal care, and went to a clinic to receive it. Did we abuse services? No, absolutely not.
What really, really pisses me off, is the fact that after the ambulance brings the patient in, her entire entourage of family and friends DRIVE IN BEHIND HER! Or, like last night, the family members arrive BEFORE the ambulance does!
Add up the costs - ambulance ride: bare minimum of several hundred dollars. Eval time in triage at the hospital - minimum $750 for basic services, double that when we charge for an NST as well. That's a total of close to $2000 (including ambulance services) that the taxpayers pay. And 9 out of 10 times, the patient is sent home.
Now, multiply that by numerous instances by the same patient. Now multiply that by numerous patients who abuse the system the same exact way.
And that's just ONE hospital.
And people wonder why the health care spending and industry is out of control????"”
(Ed. Note…[but then, you knew this was coming, didn’t you?...You know, if you are pregnant in this town, and you call the squad to your house, they have to transport you…even if your husband/fiancé/boyfriend, who has a perfectly running car sitting in the driveway, didn’t want to be bothered because he just got off work, and he was too “tired” to drive you in, or your mother (who also has a decent car sitting in the driveway) was cooking dinner and wanted to finish her meal before driving you in…so there they sit, in the recliner in the living room, or at the kitchen table, watching nonchalantly as the medics load you up on a cart and take you out to the squad. I sure hope there isn’t a serious problem going on in your neighborhood right now…like some one having a heart attack, who just might die because your significant other was too tired or your mother didn’t want her Rice-A-Roni to get cold! And, since you are not in labor, and you are not truly sick, and neither is your baby, we are sending you home, and no, we aren’t going to give you a taxi pass…CALL YOUR MOTHER!)
END OF RANT (with mucho thanks to ATC)
Monday, July 21, 2008
Equal Time...
...for nurses, residents, and physicians who work in obstetrics. In my last post I used a lengthy and extreme (but for all intents and purposes...had to change some facts to remain HIPPA compliant...true) example to whine about families who come to the hospital with expectations that they did not educate themselves about beforehand.
Well, now for the other (at least an other side) of the issue. It frustrates me how few nurses and physicians are vehemently anti-homebirth, (or any other kind of "alternative" birth) based on non-existent (e.i., their opinion), or poor research.
For a long time, all homebirth advocates had to rely 0n in terms of published research to back up their point of view was the "Tew" study, ( British Journal Obstet Gynaecol 1986 Jul;93(7):659-74) which is now over 20 years old. In a world where research over five years old is considered outdated, regardless of how well designed and carried out it may be, this is no longer going to cut it; nor are subsequent studies performed in the ninties. Now we have the Johnson/Daviss study ( BMJ 2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.14), obviously much more recent, which, even in it's criticism of it's own limitations, makes a very good case for the safety of homebirth.
So why do so many of the people I work with not know about this study, or any of the others? Why do they think that the "homebirthers" out there are uneducated women who place more value on their experience than on the safety of their baby? Why do they make fun of women who choose to give birth in any number of ways that does not jive with the "norm" of being limited in movement by I.V.s and fetal monitoring equipment, no eating or drinking in labor (not even clear liquids, heck, not even popsicles! Does someone want to tell me what the difference between one contraband popsicle and half a dozen cups of "allowed" ice chips is?), pushing in lithotomy position while holding breath, who question the need for Pitocin if they are otherwise healthy and not post-term, etc? (Yeah, I know, it's a run-on sentence, but make some allowances for passion, OK?).
In a discussion I once overheard between several of our residents and one of our attendings regarding the "trend" of waterbirth, I heard the attending exclaim "and what if you get a shoulder dystocia while you are in the water, then you are screwed!"...(uhmm, excuse me, ever heard of theGaskinManeuver???...aside from the fact that "shoulders" are more likely to occur in lithotomy position).
Recently, a doula friend of mine told me about one of her clients who asked her physician (a woman who is an excellent diagnostician, and extremely skilled surgeon, and a favorite of many of the nurses where I work - including me - who chose her to deliver their own children) if she could push in a squatting position if she felt so inclined at the time. The physician said that she wouldn't be able to have clear access for catching the baby if mom chose to do so (hmmm...how so, when the mother would be several inches above the line of view if she pushed while squatting on the bed? I bet a lot of midwives would be surprised to hear that). This particular physician is part of a huge and popular practice, so I doubt that the loss of this one patient made much of a difference to her professionally, but I wonder if it made a difference to her personally? The mother subsequently gave birth to her baby at an outlying level-one hospital, in water, attended by a physician who is gaining in popularity because he seems willing to listen to his patients, and if nothing else, empathize with them. He managed to be able to have clear enough access to deliver this child, from the floor (I assume), and through water that, in all likelihood, became at least a little murky with the fluids of birth emerging with the baby. In the first situation, a woman denied a choice to another woman, seemingly for her own personal comfort. In the second, a physician who did not have the back up of countless residents and multiple ORs felt confident enough, and was willing to respect this mother's wishes. Professionally, this gentleman is very respected where I work. He doesn't transfer cases to us just because he would rather not deal with them, he doesn't take unnecessary risks with the cases he does transfer, and the attendings that I work with just seem to like him in general...he's a "buddy" to many of them; but there were more than a few raised eyebrows when I bragged that "hey, he's willing to do it, why aren't we?" I don't think it changed their opinion of him at all...but he's certainly not holding to the status quo, and I wonder how that is going over (unsuccessfully trying not to gloat here)?
As for waterbirth? Most of the nurses I work with think it's "gross"...I mean, you can get poop in the water (as if they don't see enough poop when the mother is up in stirrups); or, all that blood and goo in the water (what, they've never had to deal with blood and goo in this job?)! Can we get consistent here folks?
I once had a patient that didn't want pitocin routinely run in after she delivered her placenta. This was written on her (albeit, a little too long for my tastes) birthplan. When one of the nurses I work with, one who does a lot of training no less, asked "Why didn't she want Pit after she delivered?", the following conversation took place between the two of us:
"Because she didn't need it".
"She didn't need it?" (I knew I was being baited here, but I couldn't resist...)
"No. No one was yanking on her placenta, so she didn't need it".
"What do you mean?" (more baiting, my irritation and irrational need to win every
"argument" taking over),
"C'mon, C, you know better...left alone, a healthy one will come out on its own, you don't need traction, and there won't be any excess bleeding to worry about".
"I don't believe that"
"Of course you don't".
"Before we started using Pit after delivery, what was the main thing women died of
in childbirth?"
"If they were otherwise healthy? Infection"
"No it wasn't...it was hemorrhage!"
"You need to go back and reread your nursing school OB textbook".
Rolled eyes, sighs, shaking head, clucking tongue...tough having a "substandard" nurse like me on the unit.
And while I'm on a roll (am I ever not?)...about infection; we've recently been required to go to "handwashing" seminars, seeing as how insurance companies are planning to deny coverage should any of their insured's end up with hospital aquired infections (another lengthy post to come on this, I guaruntee). During the presentation, the well-known (I thought) story of Dr. Ignaz Semmelweis, the physician who originated the "germ theory of disease", based on his observations of the rate of puerpural infection when physicians treating pregnant women washed their hands between corpses and other patients and the laboring and postpartum patients. I assume we all know the outcome of this story? I assume we all know the story???? Evidently not...I was amazed at the number of nurses who had no familiarity with the story! Didn't this anecdote open most of our Med/Surge, Microbiology, Obsetrical, and Community Health texts, way back in nursing school? Sigh.
By the way...the aforementioned patient whose placenta so elegantly slid out without traction, and whose body (shockingly) required no Pitocin to keep its immedate postpartum blood loss under 300 mls, had been laboring most of the time on her hands and knees. True, it was a PITA to keep her baby on the monitor, but we managed. Just about when I thought my arm would fall off though, the same nurse I would soon have the previously mentioned conversation with came in to help with the delivery (so, we have our differences, but for the most part, we're always there for each other...just like any dysfunctional family). The doc was at the end of the bed, and baby began to crown. The mother was doing a fabulous job...her perineum was beautifully pink, stretching nicely with her short, slow, powerful non-valsalva grunts and pushes...no white, blanching, evidence of an impending tear. It would have been so easy just to guide baby out, and let the nurses help Mom while she lifted her leg over baby and turned over in bed...but no, the doc insisted, baby on the perineum, that the mother turn over in the bed immediately...and as she turned, baby's head ratcheted in the opposite direction, and you guessed it...a third degree tear ensued. Ask any other nurse on my unit and it occurred because the mother was on her hands and knees (grunting like a cavewoman I heard one nurse say...arghhhhh!)...and not because she was forced, at exactly the wrong time, to work against gravity and turn over! I could scream. I know the poor mother did...so unecessary!
In this same delivery, a young nurse, a nurse-midwifery graduate student, and an excellent new L&D nurse came in to help as well. She is a lovely young woman; confident; secure; patient; a breath of fresh air when things are getting intense and the primary nurse needs a hand or a new perspective. She soothed and comforted this mother with her lovely, calm voice and demeanor. In other deliveries I've seen her in, she just has a knack for gaining the absolute trust of the woman she is caring for. After the birth, I thanked her for her help, and complimented her on what a nice addition to the floor she has become. She, in an attempt to commiserate, I can only assume replied, "You're welcome...and thankyou; but it is all so much more pleasant and controlled when the mother has an epidural. I wish she had had an epidural...it would have been so much nicer!". I was so taken aback by her comment that I just let it slide by. I've always meant to gently revisit it with her, but have never been able to find the right time (or, I must admit, the nerve) to broach the topic with her again. This is a brand, new, "malleable" L&D nurse, a future midwife, an excellent clinician, with an excellent mastery of her craft, with so much potential to bring so much respect and compassion to her clients, and it turns out to be all an act???? How dissapointing. Why do we keep potentiating this?
And there are so many excuses why we don't change. I made no secret that I was reading Jennifer Block's book, Pushed during down time on the unit. I made certain to leave it conspicuously out on the table in the nurses station when I was with a patient. Did anyone ask me about it? No. Did anyone bother to turn it over, take a look at it? Not that I'm aware of. Instead, I overhead one nurse say "That's all well and good, I suppose, but it's different in the U.S. (excuse me, but the book was written by an American author, about American women, giving birth in the American medical system)...we've all intermarried with different cultures, and we have all different sizes of pelvises, and partners, and you just can't generalize about how easy it should be to give birth when you aren't a member of a more uniform culture". She never even looked beyond the cover of the book! She had no idea what the book was about; and, if her "theory" is so true, does she want then, to explain to me how so many of our not even five-feet tall Latina patients, giving birth to 8 and 9 pound-plus babies of big, tall, husky Caucasian and African-American fathers are able to do it so easily? I've seen plenty of tiny Asian women give birth to big babies as well, with very little, if any trauma or drama. Does this woman think that the pelvis of the American woman has evolved into something mostly inadequate for birthing, in the space of under 300 years? Please. It's not our pelvises that have become dysfunctional, it's our thought processes. To have read the book and had a rational discussion of it would have made it necessary to question the illusion of our own Golden Calf.
Finally, I get so frustrated hearing my coworkers referring to the midwives in town as "Lay" midwives!!!!! They don't know what a CPM is, they don't know what MANA is, they don't know what NARM is. Why????? The few times I've attempted to "educate" them about it, I got quizzical looks from them until I showed them printed materials from both groups, including the endorsements from physicians and state governments where they are recognized as collaborative members of the health care team...then I got little more than shrugged shoulders, and they still refer to these woman as "Lay" midwives...despite the fact that the founder of the most active group of midwives in this town is internationally known! She's a gem, she's a recognized expert in her field, she's drifting quickly into retirement, and we've never taken advantage of her opinion and expertise! What a loss.
For all my griping, I really do respect the nurses I work with. They can be nothing short of awesome in a situation that is going downhill fast. Most of them love what they do, and their patients love them. They know their stuff , particularly when it comes to high risk deliveries. I seriously believe that, in a city with too many L&D units, they are the best there are. They are the first person to be there if a nurse is in a situation that is getting hairy. If someone I loved or their baby were in trouble, these would be the nurses I would want to take care of them. Honestly, I would trust my very life with them. They are that good...I just wish that they had more respect for those who make different choices than they would. I wish they had more respect for the low risk side of things. I wish they would at least examine the other view before so staunchly defending their own.
I don't get it. I just don't. These are educated people. They know how to critically read research. The information is more readily available to them than it is to anyone else.
What Gives?????
Well, now for the other (at least an other side) of the issue. It frustrates me how few nurses and physicians are vehemently anti-homebirth, (or any other kind of "alternative" birth) based on non-existent (e.i., their opinion), or poor research.
For a long time, all homebirth advocates had to rely 0n in terms of published research to back up their point of view was the "Tew" study, ( British Journal Obstet Gynaecol 1986 Jul;93(7):659-74) which is now over 20 years old. In a world where research over five years old is considered outdated, regardless of how well designed and carried out it may be, this is no longer going to cut it; nor are subsequent studies performed in the ninties. Now we have the Johnson/Daviss study ( BMJ 2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.14), obviously much more recent, which, even in it's criticism of it's own limitations, makes a very good case for the safety of homebirth.
So why do so many of the people I work with not know about this study, or any of the others? Why do they think that the "homebirthers" out there are uneducated women who place more value on their experience than on the safety of their baby? Why do they make fun of women who choose to give birth in any number of ways that does not jive with the "norm" of being limited in movement by I.V.s and fetal monitoring equipment, no eating or drinking in labor (not even clear liquids, heck, not even popsicles! Does someone want to tell me what the difference between one contraband popsicle and half a dozen cups of "allowed" ice chips is?), pushing in lithotomy position while holding breath, who question the need for Pitocin if they are otherwise healthy and not post-term, etc? (Yeah, I know, it's a run-on sentence, but make some allowances for passion, OK?).
In a discussion I once overheard between several of our residents and one of our attendings regarding the "trend" of waterbirth, I heard the attending exclaim "and what if you get a shoulder dystocia while you are in the water, then you are screwed!"...(uhmm, excuse me, ever heard of theGaskinManeuver???...aside from the fact that "shoulders" are more likely to occur in lithotomy position).
Recently, a doula friend of mine told me about one of her clients who asked her physician (a woman who is an excellent diagnostician, and extremely skilled surgeon, and a favorite of many of the nurses where I work - including me - who chose her to deliver their own children) if she could push in a squatting position if she felt so inclined at the time. The physician said that she wouldn't be able to have clear access for catching the baby if mom chose to do so (hmmm...how so, when the mother would be several inches above the line of view if she pushed while squatting on the bed? I bet a lot of midwives would be surprised to hear that). This particular physician is part of a huge and popular practice, so I doubt that the loss of this one patient made much of a difference to her professionally, but I wonder if it made a difference to her personally? The mother subsequently gave birth to her baby at an outlying level-one hospital, in water, attended by a physician who is gaining in popularity because he seems willing to listen to his patients, and if nothing else, empathize with them. He managed to be able to have clear enough access to deliver this child, from the floor (I assume), and through water that, in all likelihood, became at least a little murky with the fluids of birth emerging with the baby. In the first situation, a woman denied a choice to another woman, seemingly for her own personal comfort. In the second, a physician who did not have the back up of countless residents and multiple ORs felt confident enough, and was willing to respect this mother's wishes. Professionally, this gentleman is very respected where I work. He doesn't transfer cases to us just because he would rather not deal with them, he doesn't take unnecessary risks with the cases he does transfer, and the attendings that I work with just seem to like him in general...he's a "buddy" to many of them; but there were more than a few raised eyebrows when I bragged that "hey, he's willing to do it, why aren't we?" I don't think it changed their opinion of him at all...but he's certainly not holding to the status quo, and I wonder how that is going over (unsuccessfully trying not to gloat here)?
As for waterbirth? Most of the nurses I work with think it's "gross"...I mean, you can get poop in the water (as if they don't see enough poop when the mother is up in stirrups); or, all that blood and goo in the water (what, they've never had to deal with blood and goo in this job?)! Can we get consistent here folks?
I once had a patient that didn't want pitocin routinely run in after she delivered her placenta. This was written on her (albeit, a little too long for my tastes) birthplan. When one of the nurses I work with, one who does a lot of training no less, asked "Why didn't she want Pit after she delivered?", the following conversation took place between the two of us:
"Because she didn't need it".
"She didn't need it?" (I knew I was being baited here, but I couldn't resist...)
"No. No one was yanking on her placenta, so she didn't need it".
"What do you mean?" (more baiting, my irritation and irrational need to win every
"argument" taking over),
"C'mon, C, you know better...left alone, a healthy one will come out on its own, you don't need traction, and there won't be any excess bleeding to worry about".
"I don't believe that"
"Of course you don't".
"Before we started using Pit after delivery, what was the main thing women died of
in childbirth?"
"If they were otherwise healthy? Infection"
"No it wasn't...it was hemorrhage!"
"You need to go back and reread your nursing school OB textbook".
Rolled eyes, sighs, shaking head, clucking tongue...tough having a "substandard" nurse like me on the unit.
And while I'm on a roll (am I ever not?)...about infection; we've recently been required to go to "handwashing" seminars, seeing as how insurance companies are planning to deny coverage should any of their insured's end up with hospital aquired infections (another lengthy post to come on this, I guaruntee). During the presentation, the well-known (I thought) story of Dr. Ignaz Semmelweis, the physician who originated the "germ theory of disease", based on his observations of the rate of puerpural infection when physicians treating pregnant women washed their hands between corpses and other patients and the laboring and postpartum patients. I assume we all know the outcome of this story? I assume we all know the story???? Evidently not...I was amazed at the number of nurses who had no familiarity with the story! Didn't this anecdote open most of our Med/Surge, Microbiology, Obsetrical, and Community Health texts, way back in nursing school? Sigh.
By the way...the aforementioned patient whose placenta so elegantly slid out without traction, and whose body (shockingly) required no Pitocin to keep its immedate postpartum blood loss under 300 mls, had been laboring most of the time on her hands and knees. True, it was a PITA to keep her baby on the monitor, but we managed. Just about when I thought my arm would fall off though, the same nurse I would soon have the previously mentioned conversation with came in to help with the delivery (so, we have our differences, but for the most part, we're always there for each other...just like any dysfunctional family). The doc was at the end of the bed, and baby began to crown. The mother was doing a fabulous job...her perineum was beautifully pink, stretching nicely with her short, slow, powerful non-valsalva grunts and pushes...no white, blanching, evidence of an impending tear. It would have been so easy just to guide baby out, and let the nurses help Mom while she lifted her leg over baby and turned over in bed...but no, the doc insisted, baby on the perineum, that the mother turn over in the bed immediately...and as she turned, baby's head ratcheted in the opposite direction, and you guessed it...a third degree tear ensued. Ask any other nurse on my unit and it occurred because the mother was on her hands and knees (grunting like a cavewoman I heard one nurse say...arghhhhh!)...and not because she was forced, at exactly the wrong time, to work against gravity and turn over! I could scream. I know the poor mother did...so unecessary!
In this same delivery, a young nurse, a nurse-midwifery graduate student, and an excellent new L&D nurse came in to help as well. She is a lovely young woman; confident; secure; patient; a breath of fresh air when things are getting intense and the primary nurse needs a hand or a new perspective. She soothed and comforted this mother with her lovely, calm voice and demeanor. In other deliveries I've seen her in, she just has a knack for gaining the absolute trust of the woman she is caring for. After the birth, I thanked her for her help, and complimented her on what a nice addition to the floor she has become. She, in an attempt to commiserate, I can only assume replied, "You're welcome...and thankyou; but it is all so much more pleasant and controlled when the mother has an epidural. I wish she had had an epidural...it would have been so much nicer!". I was so taken aback by her comment that I just let it slide by. I've always meant to gently revisit it with her, but have never been able to find the right time (or, I must admit, the nerve) to broach the topic with her again. This is a brand, new, "malleable" L&D nurse, a future midwife, an excellent clinician, with an excellent mastery of her craft, with so much potential to bring so much respect and compassion to her clients, and it turns out to be all an act???? How dissapointing. Why do we keep potentiating this?
And there are so many excuses why we don't change. I made no secret that I was reading Jennifer Block's book, Pushed during down time on the unit. I made certain to leave it conspicuously out on the table in the nurses station when I was with a patient. Did anyone ask me about it? No. Did anyone bother to turn it over, take a look at it? Not that I'm aware of. Instead, I overhead one nurse say "That's all well and good, I suppose, but it's different in the U.S. (excuse me, but the book was written by an American author, about American women, giving birth in the American medical system)...we've all intermarried with different cultures, and we have all different sizes of pelvises, and partners, and you just can't generalize about how easy it should be to give birth when you aren't a member of a more uniform culture". She never even looked beyond the cover of the book! She had no idea what the book was about; and, if her "theory" is so true, does she want then, to explain to me how so many of our not even five-feet tall Latina patients, giving birth to 8 and 9 pound-plus babies of big, tall, husky Caucasian and African-American fathers are able to do it so easily? I've seen plenty of tiny Asian women give birth to big babies as well, with very little, if any trauma or drama. Does this woman think that the pelvis of the American woman has evolved into something mostly inadequate for birthing, in the space of under 300 years? Please. It's not our pelvises that have become dysfunctional, it's our thought processes. To have read the book and had a rational discussion of it would have made it necessary to question the illusion of our own Golden Calf.
Finally, I get so frustrated hearing my coworkers referring to the midwives in town as "Lay" midwives!!!!! They don't know what a CPM is, they don't know what MANA is, they don't know what NARM is. Why????? The few times I've attempted to "educate" them about it, I got quizzical looks from them until I showed them printed materials from both groups, including the endorsements from physicians and state governments where they are recognized as collaborative members of the health care team...then I got little more than shrugged shoulders, and they still refer to these woman as "Lay" midwives...despite the fact that the founder of the most active group of midwives in this town is internationally known! She's a gem, she's a recognized expert in her field, she's drifting quickly into retirement, and we've never taken advantage of her opinion and expertise! What a loss.
For all my griping, I really do respect the nurses I work with. They can be nothing short of awesome in a situation that is going downhill fast. Most of them love what they do, and their patients love them. They know their stuff , particularly when it comes to high risk deliveries. I seriously believe that, in a city with too many L&D units, they are the best there are. They are the first person to be there if a nurse is in a situation that is getting hairy. If someone I loved or their baby were in trouble, these would be the nurses I would want to take care of them. Honestly, I would trust my very life with them. They are that good...I just wish that they had more respect for those who make different choices than they would. I wish they had more respect for the low risk side of things. I wish they would at least examine the other view before so staunchly defending their own.
I don't get it. I just don't. These are educated people. They know how to critically read research. The information is more readily available to them than it is to anyone else.
What Gives?????
Thursday, July 17, 2008
Unbelievable!!!
BirthTrack Labor Progress Monitor
Intense monitoring gearing up…
This device is FDA approved and actively being marketed to hospitals.
Probes monitor real-time cervical progress and “lets you know” when the baby is ready to come out or that labor is not progressing. Takes all the guess work out of labor.
http://www.barnev. com/www.barnev. com/indexea78. html?CategoryID= 177&ArticleID= 188&Page= 1
“Barnev's Continuous Labor Monitoring System, BirthTrack, enables obstetricians to make decisions based on accurate and timely information, resulting in significantly improved medical care, reduced costs, and a lower risk of malpractice.”
A note to Mothers to Be - http://www.barnev. com/www.barnev. com/indexecca. html?CategoryID= 163
I'd file this under the "Now I've Seen Everything" label, but we all know it wouldn't be the last entry.
Intense monitoring gearing up…
This device is FDA approved and actively being marketed to hospitals.
Probes monitor real-time cervical progress and “lets you know” when the baby is ready to come out or that labor is not progressing. Takes all the guess work out of labor.
http://www.barnev. com/www.barnev. com/indexea78. html?CategoryID= 177&ArticleID= 188&Page= 1
“Barnev's Continuous Labor Monitoring System, BirthTrack, enables obstetricians to make decisions based on accurate and timely information, resulting in significantly improved medical care, reduced costs, and a lower risk of malpractice.”
A note to Mothers to Be - http://www.barnev. com/www.barnev. com/indexecca. html?CategoryID= 163
I'd file this under the "Now I've Seen Everything" label, but we all know it wouldn't be the last entry.
Back to Basics...
...as far as this blog is concerned, at least. Obstetrical Nursing.
One of the frustrations I've always had about what I do is the amount of misinformation that women today seem to have about their care during pregnancy and birth, as well as the complete lack of information on the part of some. Lately though, I've come across situations that make me begin to understand why more than a few physicians and nurses have that "rolling eyes" attitude towards women who want non-interventive births. Here is one of the more memorable examples in my own experience...
A family came to the L&D floor where I work one morning for a planned induction with one of the most conservative physicians in the area. Interestingly enough, this is one of the few practices in town that has nurse-midwives on staff, but this family was being cared for by the physician...they had never met any of the midwives. The expectant mother was accompanied by her husband, her sister, and her daughter. The husband was of a culture quite a bit more traditional (read that patriarchal) than the U.S. (as if the U.S. isn't patriarchal enough!) and his wife and daughter seemed to have adopted his customs in dress and, to a good degree, behavior. The sister was...I just can't find a "nicer" way to say this...a brash, loud woman, with garish, red, "trailer park" hair, who described herself as her sister's "doula", which she pronounced "Dowla" (think "towel" with an "a" added). When she introduced herself to me as such, I instinctively (and stupidly) corrected her "You mean doula (pronounced "doola")? "No, DOWLA", came the response, and she whipped out and handed me her sister's birthplan, all four pages of it, and set about helping her sister into bed.
Now, mind you, this family was here for a planned induction; but the birthplan, laid out "check off" style (copied from the internet), included every possible option from homebirth to a planned cesarean, and had statements like "labor to start naturally", "no I.V", water to break on it's own", "intermittent monitoring", "labor in water if desired", and, my personal favorites, "no enema" and "no shave prep".
WTF???????
Remember, that this family had chosen the care of one of the most conservative docs in town, at one of the most conservative hospitals! It was obvious that they had neither discussed this "plan" with him, nor had they researched the options available to them (unfortunately, our hospital does not offer labor or birth in water), or current birth practices. I mean, we all (don't we???) know that laboring mothers have not been given enemas or shave preps for nearly 30 years in this country! Had this mother been unconscious when her daughter was born? So, I sat down on the stool reserved for charting at the computer, birthplan in hand, asked the mother "Did you discuss your birth wishes with Dr. ____________?", to which the sister piped up, "This is a birthplan, not a wishlist!"
Enough. I had been in the room only five minutes with this family, and I had already had enough. Now, I'm not one to play "boss-nurse", but now I copped my best "Nurse Ratched" 'tude, looked "sis" square in the face and responded "And you got your dooola training where"?
"I'm self taught".
"Obviously"..."Well, my question was for your sister, not you, and hers is the only answer I will accept.
So sis turns to her sister, who was absent-mindedly smoothing her dress (she did not want to wear the hospital gown) over the fetal monitoring leads and says "She wants to know..."
"I assume she both can hear, as well as understand the question, and, again, I asked your sister the question. Please be seated, or leave the room".
Eyes squinted, shoulders squared, breath sucked in, mouth opened and something (equally loud and beligerent I assume) started coming out, but I stopped her before she could get the first syllable out..."Shall I call security?".
Glaring at me with the evil eye, she slumped down into the rocking chair next to the bed.
I continued with the mother. No, they had not discussed their birthplan with the doctor. I asked her if she understood that this was a planned induction of labor, which, by current practices of this doctor necessitated an I.V., that labor would be started by the use of drugs, continuous fetal monitoring would be required, water labor was not offered at this hospital, and that this physician would in all likelihood order her water to be broken as soon as possible. As much as I would like to, I could do very little to honor her birthplan.
She simply looked at me with a blank stare. The "dowla" left the room to "complain to your boss", and the husband left to call the doctor. Shortly after, "dowlasister" returned to the room, gathered up her purse, and left in a huff "You don't need me in this place!". Dad returned to the room, carried on an animated conversation with the mother in another language, and then turned to me "I can at least bring some tapes and other things in to make her more comfortable?" "Of course" I responded, and set about starting the mother's I.V. and getting her medical records for the stay started.
Fifteen minutes later husband was back in the room pushing a three-tiered cart piled with all manner of blankets, pillows, and two, count them two huge Rubbermaid tubs! He proceeded to take the top off of the uppermost tub, pulled out an air mattress, dragged it to the center of the floor and began to inflate it with an electric pump!
It took me a minuted to believe my eyes; then I told him that we couldn't allow the mat on the floor because it could impede the movement of people in and out of the room, especially if we had to move quickly, and especially in the event we needed to move his wife out of the room in her bed. He glared at me and began shoving the half- inflated mattress into the cabinet that is meant for an instrument table. I again apologized for not being able to meet their expectations, but that for their own safety, we could not allow the mattress. I would do as much as I possibly could to make their experience as comfortable as possible, but we had to work within the reality that this was, unfortunately, not a natural labor, but a medically induced labor, and that we needed to be able to move in and out of the room unobstructed. I also encouraged him to take as much of their "equipment" as he could back to their car, because we could not guarantee its protection should we have to leave the room for surgery. Not that I expected surgery, but you never know what might happen. Plus, he wouldn't have to worry about dragging everything to the postpartum room after the baby was born. He reluctantly agreed and started to pack back up his cart.
When I returned to the nurses station I was met with a cacophany of hoots and howls about the "nutcases in room 28", and comments about having "Jesus"on the floor (dad had long dark hair and a beard, and was wearing a long coat-like garment and sandals). I was glad to be going off shift for the day.
When I returned to work that evening, I learned that Jesus's wife had given birth uneventfully to another lovely little girl, and that everything had gone smoothly...after the father had once again inflated the airmattress on the floor, and the whole family had spread themselves out on it to watch a DVD! They had actually refused to move, so their day nurse stopped the induction (wasn't interested in catching a baby on a mattress that had been God only knows where), and called the doctor who left his office during a busy day of appointments, stormed into the room bellowing at the top of his lungs to the woman and her husband while the 10-year old ran races with her imaginary friends up and down the hallway outside the room. To this day no one knows what Dr.___________ said to the couple, but within minutes "Jesus" was meekly pushing his cart and Rubbermaid containers out to the parking garage, and mom was obediently climbing into bed.
Seriously! This actually happened!
Yes, this is an extreme example; but it's not the first time families have come to the hospital expecting things that could not be provided to them, or not having the slightest understanding of what their doctor was planning for them. They just obediently showed up at the hospital on the day "scheduled" for them, and expected things to go smoothly. If they had taken the time to think about what they would like to happen, they had never discussed it with their doctor. Many families who appear with birthplans do the same thing this family did...print one off of some site on the internet, and check off the items that some book not revised from the late sixties or early seventies suggested they put in it. When we ask them if their doctor has signed their birthplan, they seem surprised that this was necessary at all. They don't understand that it's not the hospital (as if the hospital in and of itself is a decision making entity), that determines how their care will be given, it's their doctor. Nor do they understand that they may see their doctor for, oh, 10-20 minutes...long enough for him or her to breeze in and catch a crowning baby, hand him or her off to the nurse, catch the placenta, stitch up any tears or episiotomy, and leave. Over and over I hear mothers and their family members ask "When is Dr._______ going to be here? only to be told that the doctor only comes at the end of labor. Of course, I don't know why doctors don't tell their patients this.
No, I'm not crazy about doing births the "medical" way. But Navelgazing Midwife put it best, I think "When you buy the hospital ticket, you go for the hospital ride." Of course I want your birth to be the best possible experience for you. I want to honor your wishes as best I can; but understand that I am limited to both your doctor's orders and hospital policy. If you want something different, you need to get your doctor or midwife's agreement first, and if it is something that is not normally done at this hospital, your doctor needs to make certain the arrangements can be made, within reason...and this all needs to be done weeks before your due date! Only if mothers and their families make their preferences known ahead of time, based on accurate information, can they begin to encourage change in a system that sorely needs it. It won't happen overnight, and it won't happen all at once; but it can happen, if it is handled realistically and with respect to the environment that health care professionals and workers have to negotiate.
One of the frustrations I've always had about what I do is the amount of misinformation that women today seem to have about their care during pregnancy and birth, as well as the complete lack of information on the part of some. Lately though, I've come across situations that make me begin to understand why more than a few physicians and nurses have that "rolling eyes" attitude towards women who want non-interventive births. Here is one of the more memorable examples in my own experience...
A family came to the L&D floor where I work one morning for a planned induction with one of the most conservative physicians in the area. Interestingly enough, this is one of the few practices in town that has nurse-midwives on staff, but this family was being cared for by the physician...they had never met any of the midwives. The expectant mother was accompanied by her husband, her sister, and her daughter. The husband was of a culture quite a bit more traditional (read that patriarchal) than the U.S. (as if the U.S. isn't patriarchal enough!) and his wife and daughter seemed to have adopted his customs in dress and, to a good degree, behavior. The sister was...I just can't find a "nicer" way to say this...a brash, loud woman, with garish, red, "trailer park" hair, who described herself as her sister's "doula", which she pronounced "Dowla" (think "towel" with an "a" added). When she introduced herself to me as such, I instinctively (and stupidly) corrected her "You mean doula (pronounced "doola")? "No, DOWLA", came the response, and she whipped out and handed me her sister's birthplan, all four pages of it, and set about helping her sister into bed.
Now, mind you, this family was here for a planned induction; but the birthplan, laid out "check off" style (copied from the internet), included every possible option from homebirth to a planned cesarean, and had statements like "labor to start naturally", "no I.V", water to break on it's own", "intermittent monitoring", "labor in water if desired", and, my personal favorites, "no enema" and "no shave prep".
WTF???????
Remember, that this family had chosen the care of one of the most conservative docs in town, at one of the most conservative hospitals! It was obvious that they had neither discussed this "plan" with him, nor had they researched the options available to them (unfortunately, our hospital does not offer labor or birth in water), or current birth practices. I mean, we all (don't we???) know that laboring mothers have not been given enemas or shave preps for nearly 30 years in this country! Had this mother been unconscious when her daughter was born? So, I sat down on the stool reserved for charting at the computer, birthplan in hand, asked the mother "Did you discuss your birth wishes with Dr. ____________?", to which the sister piped up, "This is a birthplan, not a wishlist!"
Enough. I had been in the room only five minutes with this family, and I had already had enough. Now, I'm not one to play "boss-nurse", but now I copped my best "Nurse Ratched" 'tude, looked "sis" square in the face and responded "And you got your dooola training where"?
"I'm self taught".
"Obviously"..."Well, my question was for your sister, not you, and hers is the only answer I will accept.
So sis turns to her sister, who was absent-mindedly smoothing her dress (she did not want to wear the hospital gown) over the fetal monitoring leads and says "She wants to know..."
"I assume she both can hear, as well as understand the question, and, again, I asked your sister the question. Please be seated, or leave the room".
Eyes squinted, shoulders squared, breath sucked in, mouth opened and something (equally loud and beligerent I assume) started coming out, but I stopped her before she could get the first syllable out..."Shall I call security?".
Glaring at me with the evil eye, she slumped down into the rocking chair next to the bed.
I continued with the mother. No, they had not discussed their birthplan with the doctor. I asked her if she understood that this was a planned induction of labor, which, by current practices of this doctor necessitated an I.V., that labor would be started by the use of drugs, continuous fetal monitoring would be required, water labor was not offered at this hospital, and that this physician would in all likelihood order her water to be broken as soon as possible. As much as I would like to, I could do very little to honor her birthplan.
She simply looked at me with a blank stare. The "dowla" left the room to "complain to your boss", and the husband left to call the doctor. Shortly after, "dowlasister" returned to the room, gathered up her purse, and left in a huff "You don't need me in this place!". Dad returned to the room, carried on an animated conversation with the mother in another language, and then turned to me "I can at least bring some tapes and other things in to make her more comfortable?" "Of course" I responded, and set about starting the mother's I.V. and getting her medical records for the stay started.
Fifteen minutes later husband was back in the room pushing a three-tiered cart piled with all manner of blankets, pillows, and two, count them two huge Rubbermaid tubs! He proceeded to take the top off of the uppermost tub, pulled out an air mattress, dragged it to the center of the floor and began to inflate it with an electric pump!
It took me a minuted to believe my eyes; then I told him that we couldn't allow the mat on the floor because it could impede the movement of people in and out of the room, especially if we had to move quickly, and especially in the event we needed to move his wife out of the room in her bed. He glared at me and began shoving the half- inflated mattress into the cabinet that is meant for an instrument table. I again apologized for not being able to meet their expectations, but that for their own safety, we could not allow the mattress. I would do as much as I possibly could to make their experience as comfortable as possible, but we had to work within the reality that this was, unfortunately, not a natural labor, but a medically induced labor, and that we needed to be able to move in and out of the room unobstructed. I also encouraged him to take as much of their "equipment" as he could back to their car, because we could not guarantee its protection should we have to leave the room for surgery. Not that I expected surgery, but you never know what might happen. Plus, he wouldn't have to worry about dragging everything to the postpartum room after the baby was born. He reluctantly agreed and started to pack back up his cart.
When I returned to the nurses station I was met with a cacophany of hoots and howls about the "nutcases in room 28", and comments about having "Jesus"on the floor (dad had long dark hair and a beard, and was wearing a long coat-like garment and sandals). I was glad to be going off shift for the day.
When I returned to work that evening, I learned that Jesus's wife had given birth uneventfully to another lovely little girl, and that everything had gone smoothly...after the father had once again inflated the airmattress on the floor, and the whole family had spread themselves out on it to watch a DVD! They had actually refused to move, so their day nurse stopped the induction (wasn't interested in catching a baby on a mattress that had been God only knows where), and called the doctor who left his office during a busy day of appointments, stormed into the room bellowing at the top of his lungs to the woman and her husband while the 10-year old ran races with her imaginary friends up and down the hallway outside the room. To this day no one knows what Dr.___________ said to the couple, but within minutes "Jesus" was meekly pushing his cart and Rubbermaid containers out to the parking garage, and mom was obediently climbing into bed.
Seriously! This actually happened!
Yes, this is an extreme example; but it's not the first time families have come to the hospital expecting things that could not be provided to them, or not having the slightest understanding of what their doctor was planning for them. They just obediently showed up at the hospital on the day "scheduled" for them, and expected things to go smoothly. If they had taken the time to think about what they would like to happen, they had never discussed it with their doctor. Many families who appear with birthplans do the same thing this family did...print one off of some site on the internet, and check off the items that some book not revised from the late sixties or early seventies suggested they put in it. When we ask them if their doctor has signed their birthplan, they seem surprised that this was necessary at all. They don't understand that it's not the hospital (as if the hospital in and of itself is a decision making entity), that determines how their care will be given, it's their doctor. Nor do they understand that they may see their doctor for, oh, 10-20 minutes...long enough for him or her to breeze in and catch a crowning baby, hand him or her off to the nurse, catch the placenta, stitch up any tears or episiotomy, and leave. Over and over I hear mothers and their family members ask "When is Dr._______ going to be here? only to be told that the doctor only comes at the end of labor. Of course, I don't know why doctors don't tell their patients this.
No, I'm not crazy about doing births the "medical" way. But Navelgazing Midwife put it best, I think "When you buy the hospital ticket, you go for the hospital ride." Of course I want your birth to be the best possible experience for you. I want to honor your wishes as best I can; but understand that I am limited to both your doctor's orders and hospital policy. If you want something different, you need to get your doctor or midwife's agreement first, and if it is something that is not normally done at this hospital, your doctor needs to make certain the arrangements can be made, within reason...and this all needs to be done weeks before your due date! Only if mothers and their families make their preferences known ahead of time, based on accurate information, can they begin to encourage change in a system that sorely needs it. It won't happen overnight, and it won't happen all at once; but it can happen, if it is handled realistically and with respect to the environment that health care professionals and workers have to negotiate.
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