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.