Thursday, April 2, 2009

On Childbirth Education

More than once in my work I've met a couple who brought with them the expectation that what they learned in childbirth class is what they would experience in the hospital. Simple, right?

Unfortunately, no.

I know a few childbirth educators. Most of them are excellent (My beloved friend C., well, she's just the absolute best of the best). Others, not so much. At least one of them is not particularly supportive of her clients who are planning to birth in a hospital (read that...she can barely contain her disgust), and therefore, not helpful at all...a total waste of her clients' time and money. Others are just plain not giving their students accurate information - for example their couples come in asking for oral vitamin k instead of injected vitamin k for their baby (we don't have it); they ask to be monitored via doppler or fetoscope (we don't have a fetoscope, and we don't have the staffing to use doppler monitoring...aside from which, no hospital is going to risk not having a paper tracing of a labor; they ask that the newborn nursery not bathe their baby, but simply massage the vernix into his or her skin (fat chance!); or, they ask to be allowed to eat during labor (good luck), or my personal favorite, not to be administered an enema or shave prep (we haven't done this in over twenty years, so I'm wondering why these particular educators are not checking to see if their information is realistic, accurate, or current). I'm not saying any of this is right, it's just what is, albeit at best unfortunate. Finally, several educators, whose classes I've not had a chance to observe, or who I don't have an opportunity to converse with often, are, well, I'm just not certain what kind of information they are giving (or not giving) to their students.

Case in point: I once cared for a sweet couple having their first baby, who were genuinely shocked that their very aggressive obstetrician was just that...extremely agressive. This couple came in, and Mom was 4 centimeters dilated, with bulging membranes. She was laboring beautifully, and I told her physician as much. As if he didn't hear a word I said, he ordered "(have a resident) Rupture her membranes, put in internals, and start 4 by 4 Pit (twice the amount of Pitocin that is normally used)". Truth be known, it was the day of "The Big Game" in our town, and Mr. MD wanted this delivery over before "all the traffic started up". Baloney...he didn't want to risk being called away from his toasty box seats, but what do I know...I've only watched this ass leave several dozen labor rooms looking like the aftermath of a suicide bombing, always in such a hurry to be done that he can't bother to leave a perineum intact, put instruments back on the table instead of dropping them on the floor, or even put his bloody gown in the biohazard can instead of tossing it aside for the nurse to pick up. This is one of those guys that make me wonder why in the hell I keep doing this.

Why indeed...because I want those who choose to give birth in a hospital to know that they have options...options that far too many physicians and nurses don't let them know they have. No, I can't monitor you with a doppler...and I can't find oral Vitamin K for your baby, but, damnit, if I don't think you need Pitocin (yet), I'll tell you...and If you want to wait until your membranes rupture on their own, and you and your baby are doing well, I'll remind you that you don't have to consent to that. If I can't "effectively facilitate communication" between physician and patient (some physicians are not interested in two-way communication), I'll advocate for my patient.

This couple stood their ground though. they gently, but firmly asked the resident who was itching to carry out their physicians orders why this was necessary. They asked for more time to make a decision. Finally, after being cajoled and hassled for hours, they gave in. They consented to having the water broken.

But we have a happy ending...for this couple at least...miracle of miracles, before the resident could finish a delivery in another room, I saw a look..."that look" come over the mother's face, and my heart nearly leapt for joy as "that look" turned into an unmistakable grimace, followed by a surprisingly loud grunt from such a petite woman, and a splash of fluid from beneath her gown spilled onto the floor, over the shoes of her startled husband, and flowed into the towel I quickly flung onto the floor to catch it. At my urging she climbed into bed just in time for her little boy to squirm his own way into the world, without Pitocin, without internal monitors, without artificial rupture of membranes, heck, without even a doctor in the room! Baby in the Bed! I loved it. Take THAT Dr. Ass (as if he if he even realized it was possible).

But for those situations that are not the recipients of such Grace, what are the Childbirth Educators in question telling their students? I wish I knew. This poor couple, when I told them what their OB wanted me to do, were absolutely stunned...who wouldn't be? They had learned in their childbirth class to stay home as long as possible, that they could avoid pitocin if the labor was progressing well, that internal monitors were an uncessary intervention if the baby was doing well and easy to trace (as was the case here), and that they should avoid having the membranes artificially ruptured if possible.

All good information; but were they encouraged the to speak with their care provider about this information? This wasn't the first couple that had come under my care with these same or similar expectations, only to be blindsided by the basic hospital "business as usuall" delivery system. All of these couples seemed genuinely confused that their physicians would order care that was so different from that they were taught to avoid.

Perhaps the educators did encourage these couples to speak with their care providers, and the couples did just that, only to be brushed off or outright lied to. Perhaps the couples, as expectant couples are sometimes apt to do, just assumed that their care provider would practice as their childbirth educator taught, so they sort of "zoned out" when the educator was advising them to speak with their so many couples do when the topic of cesarean section is brought up...they assume it won't happen to them, so they don't really listen. Or maybe, just maybe the ecucators themselves are simply teaching a philosophy...without reminding their students that theirs is not the only philosophy out there...and that, if they can, they need to learn the philosphy of both the hospital, and of the provider they are trusting to care for them during the most important moments of their lives...or at least be prepared for the possibility that they may have some significant "negotiating" ahead of them, and be given suggestions (doula anyone?) to help navigate those negotiations.

Moms, Dads, what do you think? What has been your experience? Educators, do you ever hear from your students after they give birth? What do they tell you?

Enlighten this frustrated Labor Nurse, please.


Brenda L said...

I'm guessing the requests "not to be administered an enema or shave prep" are not from childbirth classes, but from online. I'm pretty sure that every single "birth plan maker" I've seen online has those two on them, along with other odd things (like not mentioning that you can't ask for both an epidural and freedom of movement during labor).

I don't know about the hospital you work at, but at the clinic I'm going to, there are 34 different doctors that may be on call when I go into labor. I think only 1/3 of them even have office hours at the clinic I go to, so even if I were to somehow manage to have 34 prenatal visits, I couldn't see all of the doctors. One thing I realize is that, with a practice that large, even though I love the doctor I see for my checkups, I may wind up with a jerk during delivery. Honestly, I'm counting on the nurses to help me out in a case like that. Last time, the doctor wanted me to stop pushing for 45 minutes so that my epidural could wear off--I had been pushing for an hour at that point! You don't tell a woman who has been pushing for an hour to just sit around and *not* push for 45 minutes. The nurses told me that I was doing fine and I could keep on pushing.

So, I think you're doing a great job, since you advocate for your patients. But I wouldn't blame the childbirth classes, I'd put more blame on the internet. All of the things you mentioned are things I've read on the internet--very few, if any, were mentioned in my child birth class.

Anonymous said...

I'm sure some of it may be attributable to ignorance on the childbirth educator's part of what specific things are done in every hospital as a matter of course (or those that cannot be done, such as the oral vitamin K). Probably a lot of students think that just because something is technically an option, then it is theirs for the asking, and just don't understand that hospitals don't stock oral K or whatever.

It may be that some cases are pregnant couples who have just done internet research, and find birth stories, without realizing that they are not applicable in their case.

That being said, I recently came across a research study that talked about intervention rates in Canada, and some 20% of women experienced pubic shaves, and a fairly high percentage (I forget the number, but it was between 5-10%, I think) had an enema. So, even if it is not applicable to the majority of hospitals, it may still apply to some.

Also, if some women hear or read stories even from 15-20 years ago, they may think that these things are still applicable. A friend of mine at a local hospital was nearly given an enema when she had her 3rd child (in 1996). The only reason she was able to avoid it is that she was about to naturally empty her bowels. Knowing this hospital, it would not surprise me if they were still doing this, but they may have changed their practices.


Christina Kennedy said...

Interesting post! It strikes me how "in the middle" nurses sometimes are, and impresses me all the more when I read about the patient advocating you and others like you do over & over.

One of the things I tell clients (and write in my blog) over & over again is that the prep-work done before the birth is extremely important. The mom/family needs to think about how she wants the birth to go (a set of educated preferences, not demands) and then do the work she can ahead of time to set herself up well: get support from partner and/or friend/family and/or doula; choose a careprovider who is a good match; choose a birth place that's a good match etc. & etc. And then keep reflecting and communicating.

One thing I've noticed about teaching anything (I've taught high school, Sunday School, and birth classes) is that a teacher can say one thing, and there are as many interpretations of that thing as there are students. People tend to hear, in general I think, what makes sense to them, what fits in with their perceptions and experiences. So what you're seeing may or may not accurately reflect the information presented in a class.

People do zone out - so few people contact me in enough time, with enough time, to do shorter classes over more weeks. Families usually choose two or four session classes of three or four hours each. Those are *full* classes, and it's hard to pay attention and process everything.

And I think you hit on something else important to keep in mind - there are some care providers who *say* one thing and then do another, or are misleadingly ambiguous, especially if asked vague questions with no follow-up. Add that to the fact that many women get care from a practice and may or may not see all the care providers to discuss their routine management ahead of time...

Anonymous said...

I'm a doula and CBE. I attend births at several hospitals and try to keep the routines of each straight. Even within the same hospital, each OB practice has different routines. What I struggle with most is inconsistency. For example, the bath. At one hospital in the last four months, I've had clients who 1) dad bathed baby in room, 2) dad could go with nurse to nursery to observe bath, and 3) dad was told baby had to go alone. For a first time couple, the bath is a big deal. I've given up knowing what to tell them to expect. So I have some couples simply (yeah right) decline the bath altogether and get a nice biohazard tag on their baby.

I've had nurses tell me something is policy or "never happens" when I witnessed it at a birth the month before. It is hard to distinguish btwn what is a rarity (a woman squatting to deliver in a hospital w/ a 98% epidural rate) and what is policy.

I agree--it is super important for CBEs to get actual hospital experience. Ask to tag along for a birth, interview some doulas, and, absolutely, get follow-up info form your students. Even then, though, I've learned nothing seems to be written in stone on the L&D floor.

Loula said...

I taught in a hospital for two years. I made it very clear to my students that moms needed to communicate with their careproviders and that the very best they could expect at the hospital - if wanting a "natural" birth - was to have a saline lock and intermittent monitoring. I also encouraged moms to chat with their careproviders BEFORE they went into labor so they wouldn't be surprised by the aggressive management of labor when Birth day finally arrived. Informed consent and personal responsibility were major themes in my classes.

Sheridan said...

My favorite class to teach in my Hypnobabies Childbirth Education classes I teach is Class 3 where we cover the pros and cons of the different interventions that may be offered during birth. We cover many different topics from IV's to cesareans.

I like to point out that hospitals and care providers have routines. Some are willing to go outside of their comfort zone and some are not. So you need to talk to both to figure out if your desires can be met.

I talk more about that here.

I have had moms find out in discussing things with their care providers that they are not a good match for them and they end up switching.

I really try to reinforce the information to ASK questions during their birth. It is a challenge to remember everything we cover in class. So ask... Is mom Ok? Is Baby OK? If the answers are yes, then move on. BRAND, Benefits, risks, alternatives, nothing, discuss and decide.

Hopefully they will have a nurse like you to help answer those questions and support them in their choices.

webirth said...

Childbirth educators provide information but the responsiblity for acting on the information is the mother's. I do not encourage, I state outright, that I will provide a lot of information but I cannot speak to the careprovider for the mother; I cannot make her choices for her; I cannot birth her baby for her. I strongly advise women to begin natural childbirth education classes EARLY in pregnancy when there is plenty of time to learn about their options, dialogue with their careprovider and either obtain their careprovider's consent to work with the mother according to her choices OR select another careprovider whose comfort level with birth matches mother's expectations.

You can learn more about red-flag responses from careproviders that alert you your careprovider is not open and current with their information at It is also true that there are careproviders who 'yes' a mother throughout her care only to do an about face once labor commences. Consumerism is a powerful influence on birth practitioners!

Another reason why I strongly recommend beginning birth classes early in pregnancy is that today's birth environment offers a variety of obstacles to be traversed. Parents in my classes (typically a 10-week series) continue to return for "refreshers" and often comment that they absorbed information much more readily and easily the second time around. I've no idea how a mother who takes a weekend course, let alone a hospital recommended course, can say she has all the information she needs - and truly acts on that information - to have the birth she desires!

The best objective for any birth educator to transfer to a mother is that she and she alone has the power to act on information and express her choices clearly. You are correct, OB Nurse, just "hearing" that interventions don't need to be done won't make those interventions go away.

Those mothers who have a good grasp on natural childbirth information and the havoc interventions can cause, but ultimately choose an intervention will have doubled their odds of having a birth experience they didn't expect.

The Independent Childbirth Blog

yogamama said...

When it comes to natural (low-intervention) birth, I think many first-time parents desperately want the best of both worlds: intermittent monitoring, freedom to eat and drink, freedom of movement; in a nutshell, every single option for every single choice to be made -- with the comforting backdrop of advanced medical technology immediately available. And what a perfect world that would be!
As childbirth professionals I think we need to be frank with parents: You just don't get it both ways. A "good" hospital, combined with an open-minded OB or CNM, combined with a knowledgable nursing staff, will offer the opportunity for most of the options parents want. But others just aren't possible in a hospital setting. Until hospitals become more concerned with patients' needs and less concerned with litigation, many policies will limit parents' options. If things like not bathing the baby right away and oral vitamin K are important to them, these families should be in a birth center or at home. Each birth setting has its pros and cons, and choosing your birth setting can be a great exercise in "informed consent".

Curdie said...

uh, a friend of mine was given an enema (because her OB suggests it for all his laboring patients) and that was only four years ago.

ruralnurs said...

I know this post is about a month old but...

I am a nurse in a very small hospital. In our (and other small hospitals that I know of) you are much more likely to get the best of both worlds. Here you have 1:1 nurse staff, our hospital doesn’t “do” high risk OB so we try not to do things that make a patient more high risk. We almost never do internal monitoring, our docs love it when the nurse gets mom on the birth ball or in the Jacuzzi tub and we always have them up and walking. I have only seen two episiotomies in 4 years. Our docs use apricot kernel oil at the perineum and will let mom deliver herself or let dad deliver with the docs help.

I have helped deliver 2nd babies with parents that went to a “bigger is better” hospital for baby number one and they absolutely RAVE about the care they got with us. In a bigger hospital you are more likely to be just a number and need to get you moved. I have trained at some of the bigger ones and it is “PPED” “Pit” “Pop” ( the bag) “Epidural” (because they are in pain and to keep them in bed on their back) “Delivery”. We have 2 CRNAs and they are great and will stay right there. This is nice because they can do a “light” epidural and the mom has plenty of feeling (better able to move) but not pain. Many anesthesiologists will do a heavy one with lots of meds so you won’t call them back and say the mom has more pain.

We do NOT do elective inductions or God forbid elective c-sections. Our docs always deliver their own babies unless they are sick or some other big issue has arisen. We never take the babies away from the parents. We have a nursery that we can take them to when requested but we bathe in the room and do everything in the room. If parents don’t want certain things, everything is up for negotiation.

Case in point: we recently had a woman (1st baby) come in to our ER, we had never seen her so had no records on her. She came in with her lay midwife (planning a homebirth) and she had ROM for more than 24 hours. Her midwife had prepared her for immediate c-section. Our doc said she wanted to get some IV abx on board due to the long time membranes ruptured. Then put her on the monitor to see if she was having any contractions. We monitored her for awhile and no cervical change (2 cm). Our doc offered a small dose of pitocin and she accepted. We got her going and she was doing well. It was a long labor and she was getting exhausted. Our doc offered (not pushed) an epidural. The thought was this woman has been awake for about 48 hours and she was fading fast. She accepted an epidural and then slept like a log for about 4 hours. She woke up, had progressed to complete, our CRNA came in and turned the epidural off and she happily pushed for about an hour and a half and had a vaginal birth. Our doc even let the midwife help deliver.

She could not believe we worked with her, and her midwife felt so welcomed by us. She knew she was in for a c-sec and if she had gone to a big hospital she would have had it.

I think in a smaller hospital you have fewer personalities (docs) with opinions and then you have policies that get in the way. If you have complications then a big hospital is the place to be however.

I just want to put in a plug for the little rural hospitals. When I say small I mean usually a critical access hospital, less than 25 beds. Ww do about 50 deliveries per year.

RedRN said...

Ruralnurs, thanks for leaving your comment. You employer sounds like a wonderful place to work; and I totally support the mission of the Level One hospital.

I think there's a statistic out there (probably outdated) that over 80 percent of babies are born in Level One hospitals. I first learned L&D in a small town level one hospital. I loved the work, and we, too were much less interventive than what is seen in urban hospitals, even when the labor is low risk; but I don't think for a minute that Level one hospital means lower-level care. The physicians where I formerly worked were as well trained at large urban teaching centers as any obstetrician. Occasionally a high risk mother would walk in off of the street, or an existing mother would become high risk. We would stabilize her as best we could and transfer if possible, but as you well know, if Mom isn't stable, you can't transfer...and you provide care until the infant is born and support the infant (for us this sometimes meant we needed to hand-bag ventilate until the transport team arrived, but we did it). If the mom continues to be critical after giving birth, she would be transferred to the ICU until she was stable enough for transfer...if indeed she ever needed to transfer.

I think you nurses who work in rural hospitals are true heroes...out there being available to families who do not want, or may not have the resources (much less the time if timing is critical) to get to a larger urban hospital. Your community is blessed to have you in their corner.

And, thanks so much for your's given me an idea for my next, long overdue post.