I am excited to be presenting several guest posts in the upcoming weeks. While I've been feeling lately like I might have temporarily run out of things to say, a lot of the wonderful women around me are going through experiences that have given them a lot to say - and I've been shamelessly recruiting them for guest posts.
The first comes from my cousin, Maggie. We lived far apart growing up, but were close in age and shared a lot of phone calls – mostly on the topic of American Girl dolls, if I remember correctly. Now we text about breastfeeding instead! (But yes, I do have Samantha and Felicity in a box somewhere.) Maggie is pregnant with her second baby (yay, more babies in the family!) and I asked her to share her thoughts on the difference in care between her first and second pregnancies. I was so happy to get this post and see what a more positive experience she is having this time around.
Guest post: Midwife vs. OBGYN
I just went to my 34 week doctor appointment today and the first thing I told my husband after I left the appointment was, “The closer I get to my due date, the more I realize how glad I am that I changed to the midwife group.”
To give you a little background, I am pregnant with my second baby and going to a midwife group that is associated with a hospital. This means they deliver at a hospital and still have to abide by hospital rules and regulations, but they are a lot different than a typical OBGYN group.
I went to an OBGYN group during my first pregnancy. They deliver at the same hospital I am delivering at now and overall, were a nice group of women (all the docs in the group were women), but I just never felt like they cared about me. Every time I met with them I felt like I was just a number. They took my blood pressure, listened for the heartbeat and I was out the door.
I didn’t do much research about labor, pregnancy, etc until I actually was pregnant with my first and had already started to go this practice. What I know now is that I could have switched, but then I was too nervous. I felt like it was the wrong thing to do and my care would somehow be compromised. Not that I didn’t get good care there, I did, but the biggest difference between them and the midwives is that there I felt like I was just a number. They had their way of doing things and overall, they were doing it no matter what their patients wanted. I feel like the midwives treat me like a person that has opinions and feelings about how her pregnancy and labor should go. To me, that is the most important thing you can ask for in a provider, no matter who they are.
I thought the best way to really portray the difference is to give you some examples of my care at both places.
Example 1: Birth Plan
The OBGYN office did not discuss birth plans with you. The midwife office does and requires each woman to fill one out around 34 weeks. My cousin (who writes this wonderful blog) helped me put together a birth plan for my first pregnancy. I brought it to my appointment with the OB and asked her to look at it just to make sure I was on the right page. I had something in the birth plan about the hospital staff not asking me if I wanted any pain medication. The doctor’s response to this was laughing and saying, “What are the nurses supposed to do when you are lying on the floor screaming in pain?” Needless to say I left the appointment completely shaken up, crying and even more nervous about the labor.
I discussed my birth plan today with one of the midwives at my 34 week appointment. This birth plan is a lot more simplified. One thing I learned after my last pregnancy is that everything will not go according to plan and I can’t get discouraged if it doesn’t. I basically stated that I would like to try to go naturally and use certain techniques that have always helped me relax. The midwife was wonderful when going over the plan and even gave me suggestions about things to add in.
Example 2: Extras
I am not sure what to call all of the additional things that happen after the labor such as cord cutting, skin to skin contact, nursing immediately etc, but I will just call them extras. These extra things were a cause of worry for me when my first was born. Waiting to cut the cord, not cleaning the baby right away, etc were not routine for the OB practice I went to. It was just one more thing I had to worry about getting included on my plan and making sure they would follow. (Luckily they did.)
I went to a “Meet the Midwives” open house when I was first pregnant with my second and trying to decide if I should go to their practice or not. Some of the women there asked questions about cord cutting, skin to skin, etc and midwives said these are not even things that need to be included in the plan because they are all routine at their practice. In fact, the midwife I met with today even told me about a study that the hospital is doing called “Kangaroo Care” and to make sure I tell the nurses I want to be a part of it. That way I am guaranteed that all the nurses follow these procedures from birth to discharge.
Example 3: Induction
I ended up getting induced with my first. Yes, completely different than what the plan was. I was 41 weeks and the doctors recommended I get a non-stress test. Of course, we failed! My daughter’s heart deceled one time during the test and the doctor told me that I needed to get induced. Actually she told me we needed to go straight to the hospital, not to eat anything, and that I couldn’t go home and get my bags. I was freaking out! After 30 hours of Cervidil, Pitocin and an epidural my wonderful daughter was born. In the end, the labor didn’t matter. I had her vaginally and I was blessed with a wonderful, healthy daughter. But, do I want to go through that again - no way!
I discussed my last labor with the midwife today and have discussed it with my new group in the past. They basically have told me that because they are associated with a hospital if a patient gets to 41 weeks they have to recommend a non-stress test for liability reasons. Would the OB docs have told me it was a liability issue, again, no way!
They have also told me that there are more false positives than positives in a non-stress test. In fact, when I met with the midwife today I told her that I think my daughter’s heart rate never decelled. I told her that the monitor moved while I was being monitored and I believe that is when it recorded the decel. In the next 30 hours of labor my daughter’s heart rate did not drop one time. She laughed at me when I told her that. Not because she thought I was uneducated or naive, but because she could tell how strongly I felt about the whole thing. She actually went on to tell me that if I get to 41 weeks this time and get a non-stress test that I need to make sure I drink plenty of water, eat a lot before the test and “watch the monitor like a hawk.” She said if the monitor moves at all I need to pull it off, call the nurse and tell her to come put it back on. That way no false decel is being recorded. I almost grabbed her out of her chair and started kissing her when she told me that! A medical professional that is listening to me – what a novel concept!
Overall, I have had a lot better experience at my midwife group. I feel like they listen to my concerns, answer my questions and most importantly want me to have a role in my pregnancy and labor instead of just sitting back and being a passenger. That is how I felt at the OB group.
My recommendation to any pregnant women thinking about what type of practice to choose is to educate yourself first. Maybe you are okay with being a passenger, maybe you want to be in the driver’s seat. Either way, decide how you want to approach your pregnancy and pick a provider that offers you that. It has made my second pregnancy such a better experience.
Showing posts with label obs. Show all posts
Showing posts with label obs. Show all posts
Friday, March 2, 2012
Wednesday, May 18, 2011
Guest Post: Mollie's path to pregnancy/birth (Part 2: Preparation)
In Part 1, our intrepid heroine learned the secrets of her reproductive cycle and was blown away by a showing of "The Business of Being Born". Check out the next installment on...
Mollie's path to pregnancy/birth: Part 2: Preparation
So now my world had been turned upside down and I was looking for answers. Where did I go? The internet of course!!! I began following the Public Heath Doula’s blog, as well as anyone SHE followed. Soon I had a nice little list of Natural Birthing bloggers: Birth Faith, Our Bodies Our Blog, Science and Sensibility, The Unnecesarean, the Midwife Next Door, Enjoy Birth, and many others. And I read and I read and I read. I couldn’t get enough of it. Sometimes they were a little out there and scary, with a “if you give birth in a hospital you WILL end up with a cesarean”, but most of the time they were informative, and over time I learned about Doulas, episiotomy rates, c-section rates (and the vast discrepancy among hospitals in New York City, which range from 16% to 48%!), and most importantly, the questions to ask your care provider BEFORE you agree to work with them:
Questions to ask
A few more question
And a few more
Around this same time I also attended a talk given by the head of Parent Family Education from St. Luke Roosevelt Hospital. My company often holds mini lectures on topics like getting your kid into private school or how to reduce your stress at work. This one was called “Preparing for Pregnancy and Childbirth”, and thank goodness it had listed as one of the talking points “preconception” (I learned later that the instructor did not know she was expected to talk about preconception, but obliged because there were a few of us non-pregnants who showed up). The talk was basically a quick and dirty intro childbirth ed course, with an emphasis on “This is a really big deal, so after this, you should sign up for a real course.” But the most important thing that came up was this: pick your birth location BEFORE you pick your provider.
I’m going to say that last part again.
Pick your birth location BEFORE you pick your provider.
“Um, are you on crack?”, you must be thinking. “That makes no sense.” It sounded strange to me at first too, but the more I learned, the more I realized that the difference between hospitals – even hospitals within a few miles of each other – could drastically change the type of birth I would have. For example: St. Luke’s Roosevelt Hospital has an in-hospital Birthing Center, where many of the standard Labor and Delivery rules do not apply (e.g. there are no restrictions on eating or drinking, and continuous electronic fetal monitoring is not required). Approximately six miles away, Elmhurst Hospital requires every laboring woman to be confined to bed, on her back, with continuous EFM regardless of her risk assessment. The rules of the hospital would DRASTICALLY change not only my overall experience, but the specific ways I could cope with pain (if I’m not allowed out of bed except to go to the bathroom, I’m certainly not going to be allowed to walk the halls or labor on a ball).
“Well, my provider would never force me to stay in bed, and she can just meet me at the good hospital.” She could, if she has privileges there. I happen to love my gynecologist, but because of recent insurance changes, she only has privileges at Jamaica Hospital – not only inconvenient for me, but Jamaica Hospital has a 41% cesarean rate (as of 2008), compared to Roosevelt’s 28% (Read the stats here). You may decide that you want to do a home birth, but I highly doubt your OB/GYN is going to be your provider. Also, if your provider has privileges at multiple hospitals, he may have you meet him at the hospital where his current mom is laboring, not necessarily the one closest to you or the one with the amenities or rules best-suited for your desired labor experience. Now, this point may be moot if you only have one hospital or birthing center in your area, but if you live in a metropolitan area with many choices, it makes sense to get to know the hospitals first, and then ask the hospital or your insurance company for a list of practitioners with privileges at your favorite.
Ok, so I had my reproductive system down, I knew I had some options for hospitals, and I knew more about episiotomies than any child-less person should know. Over the three “preconception” months, we went on three hospital tours – Roosevelt, Lenox Hill, and The Brooklyn Birthing Center. I liked Roosevelt the best, so I asked them to send me a list of practitioners who had privileges in the Birthing Center. I narrowed down the ones covered by my insurance company (oh, side note: I called my insurance company and it was the opposite of helpful – the guy on the phone told me that midwives were illegal in the state of New York so they don’t cover them . . . oh Aetna customer service . . .), and set up consultation appointments. Now, I had no issues going on hospital tours while not yet pregnant, since they didn’t ask (I have heard rumors that some hospitals won’t let you come unless you’re pregnant, hoping to weed out trainee doulas and paparazzi I guess, but in that case, I imagine you can just lie). I got a little bit more push-back from the receptionists at the doctor’s offices (“Wait, you’re not even pregnant?!”) though thankfully, not from the doctors themselves; they knew exactly why I was meeting them so early, and even seemed to appreciate it. One midwife office (the ones I ended up choosing) actually had an orientation night, where they sat for an hour or so and talked about their practice and their birth philosophy, and where anyone could come and ask questions. I ranked my favorites, and now I was ready for baby-making!!!
Mollie's path to pregnancy/birth: Part 2: Preparation
So now my world had been turned upside down and I was looking for answers. Where did I go? The internet of course!!! I began following the Public Heath Doula’s blog, as well as anyone SHE followed. Soon I had a nice little list of Natural Birthing bloggers: Birth Faith, Our Bodies Our Blog, Science and Sensibility, The Unnecesarean, the Midwife Next Door, Enjoy Birth, and many others. And I read and I read and I read. I couldn’t get enough of it. Sometimes they were a little out there and scary, with a “if you give birth in a hospital you WILL end up with a cesarean”, but most of the time they were informative, and over time I learned about Doulas, episiotomy rates, c-section rates (and the vast discrepancy among hospitals in New York City, which range from 16% to 48%!), and most importantly, the questions to ask your care provider BEFORE you agree to work with them:
Questions to ask
A few more question
And a few more
Around this same time I also attended a talk given by the head of Parent Family Education from St. Luke Roosevelt Hospital. My company often holds mini lectures on topics like getting your kid into private school or how to reduce your stress at work. This one was called “Preparing for Pregnancy and Childbirth”, and thank goodness it had listed as one of the talking points “preconception” (I learned later that the instructor did not know she was expected to talk about preconception, but obliged because there were a few of us non-pregnants who showed up). The talk was basically a quick and dirty intro childbirth ed course, with an emphasis on “This is a really big deal, so after this, you should sign up for a real course.” But the most important thing that came up was this: pick your birth location BEFORE you pick your provider.
I’m going to say that last part again.
Pick your birth location BEFORE you pick your provider.
“Um, are you on crack?”, you must be thinking. “That makes no sense.” It sounded strange to me at first too, but the more I learned, the more I realized that the difference between hospitals – even hospitals within a few miles of each other – could drastically change the type of birth I would have. For example: St. Luke’s Roosevelt Hospital has an in-hospital Birthing Center, where many of the standard Labor and Delivery rules do not apply (e.g. there are no restrictions on eating or drinking, and continuous electronic fetal monitoring is not required). Approximately six miles away, Elmhurst Hospital requires every laboring woman to be confined to bed, on her back, with continuous EFM regardless of her risk assessment. The rules of the hospital would DRASTICALLY change not only my overall experience, but the specific ways I could cope with pain (if I’m not allowed out of bed except to go to the bathroom, I’m certainly not going to be allowed to walk the halls or labor on a ball).
“Well, my provider would never force me to stay in bed, and she can just meet me at the good hospital.” She could, if she has privileges there. I happen to love my gynecologist, but because of recent insurance changes, she only has privileges at Jamaica Hospital – not only inconvenient for me, but Jamaica Hospital has a 41% cesarean rate (as of 2008), compared to Roosevelt’s 28% (Read the stats here). You may decide that you want to do a home birth, but I highly doubt your OB/GYN is going to be your provider. Also, if your provider has privileges at multiple hospitals, he may have you meet him at the hospital where his current mom is laboring, not necessarily the one closest to you or the one with the amenities or rules best-suited for your desired labor experience. Now, this point may be moot if you only have one hospital or birthing center in your area, but if you live in a metropolitan area with many choices, it makes sense to get to know the hospitals first, and then ask the hospital or your insurance company for a list of practitioners with privileges at your favorite.
Ok, so I had my reproductive system down, I knew I had some options for hospitals, and I knew more about episiotomies than any child-less person should know. Over the three “preconception” months, we went on three hospital tours – Roosevelt, Lenox Hill, and The Brooklyn Birthing Center. I liked Roosevelt the best, so I asked them to send me a list of practitioners who had privileges in the Birthing Center. I narrowed down the ones covered by my insurance company (oh, side note: I called my insurance company and it was the opposite of helpful – the guy on the phone told me that midwives were illegal in the state of New York so they don’t cover them . . . oh Aetna customer service . . .), and set up consultation appointments. Now, I had no issues going on hospital tours while not yet pregnant, since they didn’t ask (I have heard rumors that some hospitals won’t let you come unless you’re pregnant, hoping to weed out trainee doulas and paparazzi I guess, but in that case, I imagine you can just lie). I got a little bit more push-back from the receptionists at the doctor’s offices (“Wait, you’re not even pregnant?!”) though thankfully, not from the doctors themselves; they knew exactly why I was meeting them so early, and even seemed to appreciate it. One midwife office (the ones I ended up choosing) actually had an orientation night, where they sat for an hour or so and talked about their practice and their birth philosophy, and where anyone could come and ask questions. I ranked my favorites, and now I was ready for baby-making!!!
Friday, April 22, 2011
Short but sweet on why dads/partners should love doulas
Trying to convince a reluctant family member of your need to have a doula? Try this quote on them, from an OB-GYN I know who had a doula at her first birth: "I can't say if having a doula shortened my labor, but it definitely lengthened my marriage!"
Thursday, March 24, 2011
Breastfeeding and Feminism, Day 2 (...2 weeks later)
My Lent resolution has apparently not yet translated into more posting! A few factors have contributed to that, among them my new full-time job(!) I have gone from per diem at the hospital working 24ish hours a week, to full-time working 36 hours a week (three 12-hour night shifts). Going from working 8-hour shifts to 12-hour shifts is a surprisingly big adjustment (although fortunately not as big an adjustment as beginning to work nights was.) There are drawbacks to my new schedule (less flexibility, losing several evenings, etc.) but the benefits are, well, the benefits! Apart from my grad school assistantships, I haven't had a job with health insurance since I was in AmeriCorps. I am looking forward to having good health insurance, along with retirement benefits. One of my goals in going to grad school was to finally get a "real" job with salary + benefits, and while it didn't happen in exactly the field I expected it to, I couldn't be more pleased (except for the part where I work nights. Hopefully someday I'll work days again!)
Now that I've made my excuses, long-delayed highlights from the second day of the Breastfeeding & Feminism conference:
* Possibly my favorite presentation of the day was Robbie Davis-Floyd's report on the International MotherBaby Childbirth Initiative. Based on the Baby-Friendly initiative, the IMBCI has outlined 10 Steps to optimal motherbaby maternity services, developed with the input of organizations around the world. Steps include treating every woman with respect and dignity, offering continuous labor support, providing evidence-based practices, and providing access to emergency OB care. Three sites have applied and been accepted to become demonstration sites, one each in Austria, Brazil, and Quebec, Canada. You can read more about the (very diverse!) demonstration sites here. She discussed more about the sites and more details of their applications. She also talked about sites that will be added soon, in South Africa, Mozambique, India, and - amazingly - the largest maternity hospital in the Philippines, which does 22,000 births a year (I cannot even imagine). It's inspirational to see institutions from countries with different levels of development and each with their own unique strengths and challenges, working on the aim of improving maternity care. I am so excited to see ow the demonstration projects go.
* Michelle Lauria, an OB-GYN from Dartmouth, gave a great talk on reducing late preterm birth, a project of the Northern New England Perinatal Quality Improvement Network. She also talked about eliminating elective inductions before 39 weeks, and in mothers who do not have a high enough Bishop's score. She said the key is to put power in the hands of the nursing staff with the hospital authorities backing them up; the doctors know if they send someone in for an induction who does not meet the guidelines, the charge nurse will send them right back home. She talked about the next step being setting stricter guidelines on ways that some doctors use to get around the restrictions; she gave the example of mildly elevated blood pressures without proteinuria being called pre-eclampsia and used as a reason to induce early.
She also discussed VBAC at some length. Her take on it was, in her region, it's all about the money - as in, medical malpractice insurance costs. In northern New England, which has a lot of isolated rural communities, she gave an example of a small regional hospital that wants to offer VBACs but would have to pay $120,000 more in malpractice insurance to do so. Given that they anticipate 2 VBACs a year, they would end up paying an extra $60,000 per VBAC. Her proposed solutions are both governmental: either medical malpractice reform of some kind, or for the government to coordinate regional VBAC centers. There would be one hospital in each region designated as the VBAC center, and all the other maternity hospitals would contribute towards the VBAC center's additional malpractice insurance. She considers this unrealistic without government intervention because of the nature of competition between hospitals.
* Beverly Rossman from Rush in Chicago did a very inspiring presentation on breastfeeding peer counselors in the NICU. The NICU breastfeeding peer counselors are truly peers - they are women who have personal breastfeeding experience with very low birthweight (VLBW) babies. She summarized some themes from qualitative interviews from mothers who worked with the peer counselors: instrumental support, emotional support, finding hope, empowerment, community, and emulation. Over and over again the interviewees talked about how much they identified with the peer counselors, how much hope they drew from seeing mothers who had been in their situation, and how important the emotional support was. It left me wanting a breastfeeding peer counselor program in our NICU so badly! (If you'd like to learn more and you have access to the Journal of Human Lactation, you can check out their journal article. Citation: Rossman, Meier, Engstrom, Verheed, Norr & Hill. "They've Walked in My Shoes": Mothers of Very Low Birth Weight Infants and Their Experiences with Breastfeeding Peer Counselors in the Neonatal Intensive Care Unit. JHL. 2011. 27(1):14-24.)
It was a great conferences with some great conversation! It was hard to choose between the CIMS and the BF & Feminism tracks sometimes because there was so much interesting stuff going on, but I'm glad they combined the conferences for the opportunity to pick and choose from both programs.
Sadly, I won't be able to go to the CLPP Reproductive Justice conference this year. Please, everyone who's going tell me all about it! I am determined to go next year.
Now that I've made my excuses, long-delayed highlights from the second day of the Breastfeeding & Feminism conference:
* Possibly my favorite presentation of the day was Robbie Davis-Floyd's report on the International MotherBaby Childbirth Initiative. Based on the Baby-Friendly initiative, the IMBCI has outlined 10 Steps to optimal motherbaby maternity services, developed with the input of organizations around the world. Steps include treating every woman with respect and dignity, offering continuous labor support, providing evidence-based practices, and providing access to emergency OB care. Three sites have applied and been accepted to become demonstration sites, one each in Austria, Brazil, and Quebec, Canada. You can read more about the (very diverse!) demonstration sites here. She discussed more about the sites and more details of their applications. She also talked about sites that will be added soon, in South Africa, Mozambique, India, and - amazingly - the largest maternity hospital in the Philippines, which does 22,000 births a year (I cannot even imagine). It's inspirational to see institutions from countries with different levels of development and each with their own unique strengths and challenges, working on the aim of improving maternity care. I am so excited to see ow the demonstration projects go.
* Michelle Lauria, an OB-GYN from Dartmouth, gave a great talk on reducing late preterm birth, a project of the Northern New England Perinatal Quality Improvement Network. She also talked about eliminating elective inductions before 39 weeks, and in mothers who do not have a high enough Bishop's score. She said the key is to put power in the hands of the nursing staff with the hospital authorities backing them up; the doctors know if they send someone in for an induction who does not meet the guidelines, the charge nurse will send them right back home. She talked about the next step being setting stricter guidelines on ways that some doctors use to get around the restrictions; she gave the example of mildly elevated blood pressures without proteinuria being called pre-eclampsia and used as a reason to induce early.
She also discussed VBAC at some length. Her take on it was, in her region, it's all about the money - as in, medical malpractice insurance costs. In northern New England, which has a lot of isolated rural communities, she gave an example of a small regional hospital that wants to offer VBACs but would have to pay $120,000 more in malpractice insurance to do so. Given that they anticipate 2 VBACs a year, they would end up paying an extra $60,000 per VBAC. Her proposed solutions are both governmental: either medical malpractice reform of some kind, or for the government to coordinate regional VBAC centers. There would be one hospital in each region designated as the VBAC center, and all the other maternity hospitals would contribute towards the VBAC center's additional malpractice insurance. She considers this unrealistic without government intervention because of the nature of competition between hospitals.
* Beverly Rossman from Rush in Chicago did a very inspiring presentation on breastfeeding peer counselors in the NICU. The NICU breastfeeding peer counselors are truly peers - they are women who have personal breastfeeding experience with very low birthweight (VLBW) babies. She summarized some themes from qualitative interviews from mothers who worked with the peer counselors: instrumental support, emotional support, finding hope, empowerment, community, and emulation. Over and over again the interviewees talked about how much they identified with the peer counselors, how much hope they drew from seeing mothers who had been in their situation, and how important the emotional support was. It left me wanting a breastfeeding peer counselor program in our NICU so badly! (If you'd like to learn more and you have access to the Journal of Human Lactation, you can check out their journal article. Citation: Rossman, Meier, Engstrom, Verheed, Norr & Hill. "They've Walked in My Shoes": Mothers of Very Low Birth Weight Infants and Their Experiences with Breastfeeding Peer Counselors in the Neonatal Intensive Care Unit. JHL. 2011. 27(1):14-24.)
It was a great conferences with some great conversation! It was hard to choose between the CIMS and the BF & Feminism tracks sometimes because there was so much interesting stuff going on, but I'm glad they combined the conferences for the opportunity to pick and choose from both programs.
Sadly, I won't be able to go to the CLPP Reproductive Justice conference this year. Please, everyone who's going tell me all about it! I am determined to go next year.
Friday, January 14, 2011
Defensive medicine and the c-section assembly line
Apologies for the long posting silence. I have so many drafts in progress. In the meantime, I want to direct people to the excellent and thought-provoking posts and comments at the Unnecesarean's series Defending Ourselves Against Defensive Medicine.
I thought I would tell a little story to go with it. My last CenteringPregnancy group had their reunion today. The midwife organizes it so that the reunion takes place at the meeting of a group who is about to have their babies. Then the new moms can share their experiences of birth, breastfeeding, and baby care with the moms-to-be.
One of the reunion moms had quite the story. She had 3 days of labor and was finally at the hospital making very slow progress with a posterior baby. The midwife who facilitated the group was working with her and the doctor came in to tell the midwife that the woman should have a c-section.
The midwife took him out into the hallway to discuss it. Turns out he had a morbidly obese patient who was also going to need a c-section, and would need the OR and a number of staff for a significant amount of time. The doctor's take was, "Let's get this one out of the way, then we'll do the more complicated surgery." The midwife went to bat and said "No. Mom is fine and baby is fine. I know my patient is stalled, but you do this longer surgery and THEN, if she's still not progressed, you can take her to the OR." They argued and (thankfully!) the midwife won. She went back in and put mom in a knee chest position (keep in mind this was a mom who had an epidural! these positions are possible under many circumstances!) The baby rotated to OA, and after that labor progressed and baby was born easily.
Thank goodness for guardian midwives in the face of not just defensive but assembly-line medicine.
I thought I would tell a little story to go with it. My last CenteringPregnancy group had their reunion today. The midwife organizes it so that the reunion takes place at the meeting of a group who is about to have their babies. Then the new moms can share their experiences of birth, breastfeeding, and baby care with the moms-to-be.
One of the reunion moms had quite the story. She had 3 days of labor and was finally at the hospital making very slow progress with a posterior baby. The midwife who facilitated the group was working with her and the doctor came in to tell the midwife that the woman should have a c-section.
The midwife took him out into the hallway to discuss it. Turns out he had a morbidly obese patient who was also going to need a c-section, and would need the OR and a number of staff for a significant amount of time. The doctor's take was, "Let's get this one out of the way, then we'll do the more complicated surgery." The midwife went to bat and said "No. Mom is fine and baby is fine. I know my patient is stalled, but you do this longer surgery and THEN, if she's still not progressed, you can take her to the OR." They argued and (thankfully!) the midwife won. She went back in and put mom in a knee chest position (keep in mind this was a mom who had an epidural! these positions are possible under many circumstances!) The baby rotated to OA, and after that labor progressed and baby was born easily.
Thank goodness for guardian midwives in the face of not just defensive but assembly-line medicine.
Thursday, December 16, 2010
Yes, Virginia, crappy OBs really do exist
I read and enjoy several blogs by physicians including OBs. One theme I hear frequently repeated by those doctors is (if I may paraphrase) "the natural birth community (particularly online) paints all OBs as evil/uncaring/c-section happy/in a rush to get to our golf game. I am not like that" - sometimes then there is a chorus of "well YOU are very rare and special" from the commenters - "and my colleagues are not like that. They are wonderful people who care about their patients."
I believe that there are caring, dedicated OBs out there and I believe they are in the majority. Keep in mind that this doesn't mean I believe their caring and dedication play out in ways that are always mother-friendly. I also believe there are OBs who routinely practice in a way that is based on informed consent, patient choice, and respectful communication even when the patient disagrees with them or wants to diverge from their standard practice; I sometimes have difficulty believing they're in the majority, but I don't believe they're rare, special pearls.
However, I do think that the proportion of non-evidence based, aggressive, and/or insensitive OBs is higher than the other OBs realize. They just don't routinely see each other in practice. In a teaching hospital where there are residents, fellows, attendings, etc. all working together this is less true, but once OBs are out in the community in their own practices, they're not following each other around to see what goes on inside the exam room or in L&D. So behavior like this happens to women, is reported by those women or by observers, and is disregarded by OBs as "My colleagues are good people. They're not like that." You can be a nice, caring person and still be like this:
From labor nurse At Your Cervix.
I doubt that this doctor walks around with horns sprouting out of his head, or telling OB colleagues how much he hates his patients. He may even be lovely to some of his patients, or lovely in certain situations. But I think it's OK to admit that not everyone knows what goes on behind closed doors, and that when women tell their stories of inappropriate treatment, we should validate and honor those stories. The kneejerk response should not be "No one I know would do that - we are good people" (and neither should it be "All OBs are EVIIIIIL"). Because clearly, someone IS doing that - and why couldn't it be someone you know?
I believe that there are caring, dedicated OBs out there and I believe they are in the majority. Keep in mind that this doesn't mean I believe their caring and dedication play out in ways that are always mother-friendly. I also believe there are OBs who routinely practice in a way that is based on informed consent, patient choice, and respectful communication even when the patient disagrees with them or wants to diverge from their standard practice; I sometimes have difficulty believing they're in the majority, but I don't believe they're rare, special pearls.
However, I do think that the proportion of non-evidence based, aggressive, and/or insensitive OBs is higher than the other OBs realize. They just don't routinely see each other in practice. In a teaching hospital where there are residents, fellows, attendings, etc. all working together this is less true, but once OBs are out in the community in their own practices, they're not following each other around to see what goes on inside the exam room or in L&D. So behavior like this happens to women, is reported by those women or by observers, and is disregarded by OBs as "My colleagues are good people. They're not like that." You can be a nice, caring person and still be like this:
Well, the OB feels this need to check her cervix again. After I just did the same thing less than 2 minutes before. I even said - "hey, I just checked her. She's still only 7-8 cm. But she's hurting bad in that one spot, so anesthesia is coming up to re-dose her."
"You think I can stretch her to 10cm?" he asks.
"No way. Cervix is too thick all the way around." I tell him as I cringe at the thought of manually opening her cervix when she is in such excruciating pain to begin with.
The OB insists on checking her again. And forces her cervix open another 1-2 cm. The woman is screaming at the top of her lungs through all of this. I'm giving the doc the evil eye, and telling him again - "anesthesia is coming up. This woman deserves some better pain relief!"
The OB is telling the woman to push through it.
Fucker.
I look at the woman and mouth "I'm so sorry" to her.
From labor nurse At Your Cervix.
I doubt that this doctor walks around with horns sprouting out of his head, or telling OB colleagues how much he hates his patients. He may even be lovely to some of his patients, or lovely in certain situations. But I think it's OK to admit that not everyone knows what goes on behind closed doors, and that when women tell their stories of inappropriate treatment, we should validate and honor those stories. The kneejerk response should not be "No one I know would do that - we are good people" (and neither should it be "All OBs are EVIIIIIL"). Because clearly, someone IS doing that - and why couldn't it be someone you know?
Wednesday, July 14, 2010
Alert, someone is wrong on the Internet!
Some discussion going on in the comments at Science and Sensibility's post on the new meta-analysis of home birth in AJOG. Aaaand I let myself get drawn in. Funny how that happens when I have about six other projects I could be working on. I trace it to a moment of intrigue when one of the commenters stated that the Netherlands has poorer perinatal outcomes than the rest of Europe both at home and in the hospital because there are so many midwives that there isn't enough emergency OB care/neonatal services even in the hospital. All those midwives, taking up space, and just no room for OBs or pediatricians! So I went and looked around for some published evidence on that, and all I found was a BMJ summary of a Dutch government report that recommended, among other things, better emergency OB availability in small community hospitals. I responded pointing out that the U.S. also lacks immediate emergency OB care in many small community hospitals and we can't really attribute that to a surplus of midwives. But heck, maybe this commenter knew something I didn't? Maybe they spent years as a maternity nurse in the Netherlands! Maybe they speak fluent Dutch and this is all over the Dutch perinatal literature! Who knows!
Sadly, the reply to that was basically a lot of name-calling accusing, apparently, all midwives everywhere of being shameful liars. I know, I know. Having (hopefully) extricated myself, I'll slink back to studying for the IBCLC exam. Eleven more days, ack!
In the meantime, if anyone has any actual insights over this whole Dutch emergency OB care thing, I'd be curious to know.
Sadly, the reply to that was basically a lot of name-calling accusing, apparently, all midwives everywhere of being shameful liars. I know, I know. Having (hopefully) extricated myself, I'll slink back to studying for the IBCLC exam. Eleven more days, ack!
In the meantime, if anyone has any actual insights over this whole Dutch emergency OB care thing, I'd be curious to know.
Friday, March 26, 2010
You buy the hospital ticket, you go for the hospital ride, Part 235624
The Feminist Breeder posted a link today to a friend's blog post about an OB and an L&D nurse discussing c-sections on Facebook. The OB said she was up late waiting for a baby to come out, the L&D nurse recommended "Ahhh just cut her, fuk it!" and when called out for this both the OB and the nurse defended each other, with the nurse loading on some extra distaste for "birth plans".
I actually don't think the OB's original comment was so out of line. I've (obliquely) sighed over a long induction on FB, and I have friends in many jobs (including medical ones) who vent a little bit at the end of a long shift or a tough task. It was really the nurse's response(s) that I thought deserved the ire that's being generated.
And as I was scrolling through all of said ire in the comments, I came across a great comment from Navelgazing Midwife that I wanted to repost here in part. She is responding to many of the people asking why the nurse was hating so much on birth plans.
Doctors and nurses HATE birth plans. Have for years. (There are a minute few who accept them.) The reason the nurse said it sets women up for failure is because the hospital system is not equipped to permit/allow/encourage women to have an autonomous labor and birth. The hospital assembly line moves one way - through as much technology as possible. Asking a nurse to attend to a woman "wandering the halls" (as I've heard said many times before) is unfair because she has other patients to take care of, too. If the patient wants intermittent monitoring, wants to get up periodically, wants to eat and drink in labor, wants to push out of the bed, wants to do without an IV... all of these things cramp the hospital and nurse's (and OB's) style, making their jobs much more difficult... AND, in their eyes, opens them up for some serious liability. *We* can say, "Tough caca. They need to do what we want because we're hiring them and it's my birth," but they can be quite persuasive and manipulative, threatening women in the middle of what should be a glorious experience.
I use the phrase, "You buy the hospital ticket, you go for the hospital ride" because if you want a homebirth in the hospital, you will be sorely disappointed (the "set-up for failure" the nurse speaks of). If you want a homebirth, have a homebirth. Otherwise, acknowledge the limitations, choreograph what you can and don't be surprised if your birth doesn't turn out like you envisioned.
The same can be said about doulas; hospitals, nurses and doctors generally despise them. They get in the way of the care provider's directions, they "make" women question the status quo and rock the boat of misogyny and anonymity in the hospital's birthing assembly line. Some dislike doulas so much, they refuse to work with a client who has one -and some hospitals have banned them altogether.
If a woman feels like she's going into battle in the hospital, I would *highly* encourage her to seek out other options (new doc, new hospital, etc.) if at all possible. I do understand that not everyone has that luxury, but many do. I hope they exercise their power of economics to hire someone who respects them.
I will add the caveat that I don't think that hospitals, nurses, and doctors "generally" despise doulas, birth plans, etc. because I have now worked at multiple hospitals and I would say that generally I have been well-received as a doula - the haters have been the exception, not the rule - and I haven't seen much open disdain for birth plans although I could imagine it's taking place behind the scenes.
But apart from that I will say a big YES YES YES to the rest of this. I know I've posted about it before but I just had to do it again, because I've heard a little too much lately about people's basic dignity being disrespected in the hospital and/or by care providers. Some of these people can change and do, some can and don't, some are stuck with their "hospital ticket" and the ride that it entails.
In short: it's hard to fight the tide of people, like the nurse in the post, who put quotes around the words "birth plans", coming at you in the hospital who are used to getting things done their way, who have gotten things done their way with the 15 other women they've worked with this week, and at all of the 2,500 other births they've worked at in their career. If you think you can buck the tide, ask yourself, who has more practice getting births done their way, you or them? And then prepare yourself thoroughly for resistance, because at best you won't need it and more likely, you will.
(My goodness, all my posts lately have been not very positive, have they? I blame the deadline for my master's paper putting me in a negative frame of mind.)
I actually don't think the OB's original comment was so out of line. I've (obliquely) sighed over a long induction on FB, and I have friends in many jobs (including medical ones) who vent a little bit at the end of a long shift or a tough task. It was really the nurse's response(s) that I thought deserved the ire that's being generated.
And as I was scrolling through all of said ire in the comments, I came across a great comment from Navelgazing Midwife that I wanted to repost here in part. She is responding to many of the people asking why the nurse was hating so much on birth plans.
Doctors and nurses HATE birth plans. Have for years. (There are a minute few who accept them.) The reason the nurse said it sets women up for failure is because the hospital system is not equipped to permit/allow/encourage women to have an autonomous labor and birth. The hospital assembly line moves one way - through as much technology as possible. Asking a nurse to attend to a woman "wandering the halls" (as I've heard said many times before) is unfair because she has other patients to take care of, too. If the patient wants intermittent monitoring, wants to get up periodically, wants to eat and drink in labor, wants to push out of the bed, wants to do without an IV... all of these things cramp the hospital and nurse's (and OB's) style, making their jobs much more difficult... AND, in their eyes, opens them up for some serious liability. *We* can say, "Tough caca. They need to do what we want because we're hiring them and it's my birth," but they can be quite persuasive and manipulative, threatening women in the middle of what should be a glorious experience.
I use the phrase, "You buy the hospital ticket, you go for the hospital ride" because if you want a homebirth in the hospital, you will be sorely disappointed (the "set-up for failure" the nurse speaks of). If you want a homebirth, have a homebirth. Otherwise, acknowledge the limitations, choreograph what you can and don't be surprised if your birth doesn't turn out like you envisioned.
The same can be said about doulas; hospitals, nurses and doctors generally despise them. They get in the way of the care provider's directions, they "make" women question the status quo and rock the boat of misogyny and anonymity in the hospital's birthing assembly line. Some dislike doulas so much, they refuse to work with a client who has one -and some hospitals have banned them altogether.
If a woman feels like she's going into battle in the hospital, I would *highly* encourage her to seek out other options (new doc, new hospital, etc.) if at all possible. I do understand that not everyone has that luxury, but many do. I hope they exercise their power of economics to hire someone who respects them.
I will add the caveat that I don't think that hospitals, nurses, and doctors "generally" despise doulas, birth plans, etc. because I have now worked at multiple hospitals and I would say that generally I have been well-received as a doula - the haters have been the exception, not the rule - and I haven't seen much open disdain for birth plans although I could imagine it's taking place behind the scenes.
But apart from that I will say a big YES YES YES to the rest of this. I know I've posted about it before but I just had to do it again, because I've heard a little too much lately about people's basic dignity being disrespected in the hospital and/or by care providers. Some of these people can change and do, some can and don't, some are stuck with their "hospital ticket" and the ride that it entails.
In short: it's hard to fight the tide of people, like the nurse in the post, who put quotes around the words "birth plans", coming at you in the hospital who are used to getting things done their way, who have gotten things done their way with the 15 other women they've worked with this week, and at all of the 2,500 other births they've worked at in their career. If you think you can buck the tide, ask yourself, who has more practice getting births done their way, you or them? And then prepare yourself thoroughly for resistance, because at best you won't need it and more likely, you will.
(My goodness, all my posts lately have been not very positive, have they? I blame the deadline for my master's paper putting me in a negative frame of mind.)
Saturday, February 13, 2010
Link party!
First of all, Happy Olympics! I am so excited. I love the Olympics. My department had an Olympics party last night - come as your favorite athlete, sport, or country. We had everything from Brian Boitano to bobsledding to several people all in white ("Winter") and one Olympic torch. I was Sweden, which is a good Winter Olympics country to pick.
I've been trying to come up with some kind of play on words with the Olympics starting, Olympic rings, the rings are linked, links...I think I'm trying too hard. So let's just say that my Google Reader starred list is becoming too long to contemplate, and that it's time for a link party. I've been saving some of these up thinking "I'll write a post on this!" but the truth is, I might or might not eventually, and in the meantime why let the starred list get longer?
Academic review article on the risks of not breastfeeding for mothers and infants, and the role of obstetricians and hospitals in breastfeeding promotion. A very nice summary.
Via Empowering Birth blog, an informed consent roleplay. Has anyone ever used this with a class? It seems like a great idea to get people prepared to actually advocate for themselves - it's easy to talk about it beforehand, and harder to actually do in the moment.
And another link from Enjoy Birth about choosing hospitals wisely.
A dad talks about his thoughts on breastfeeding.
At Guerilla Mama Medicine, HUGELY important questions and thoughts about race and the natural childbirth movement.
An article from RH Reality Check about The Doula Project, which provides doulas for women who are having abortions and who are relinquishing their babies for adoption. I'm proud to say that I know one of the co-founders, Lauren Mitchell, who has an awesome quote in the piece: "You can't speak for your client, even if what's going on is the opposite of what she wanted - you're not in control of the room. But you are in control of what you are giving your client, and that is an informed ally and a deeply empathetic presence. When you're a doula you have to acknowledge how to be 'human' even when you want to be more than that. What keeps me going is the feedback from the clients that the space that I've created for them is unique and extremely important." If I end up back in NYC I would LOVE to volunteer with them!
From Birth Sense, thoughts about manual rotation of the fetal head. I have seen this happen once, and it was very effective - baby went from making very little progress with pushes, to crowning within minutes. But the midwife writing the article reminds us that it's also extremely important to move the mother!
I've also been enjoying Birth Sense's series, "Your Doctor or Midwife Still Does WHAT?" Here's a sample: #5, Cervical Exams. Reading expectant mothers' blogs I come across so many sighing with frustration that they're still not dilated at all, when is this baby going to come, etc. etc. Since there are very few actual medical reasons to do a cervical exam, it starts to seem like a highly effective method of psychological priming for induction.
Navelgazing Midwife did a great series of photo posts called "Teachable Moments" about placentas, vernix, trailing membranes, etc. Here's a great one on being born in the caul. I guess I should put in a disclaimer that these photos involve vaginas and birth fluids and stuff like that, although I have such a high tolerance at this point I have to remind myself that somebody else might need a warning.
That's all for now - off to watch me some Olympics!
I've been trying to come up with some kind of play on words with the Olympics starting, Olympic rings, the rings are linked, links...I think I'm trying too hard. So let's just say that my Google Reader starred list is becoming too long to contemplate, and that it's time for a link party. I've been saving some of these up thinking "I'll write a post on this!" but the truth is, I might or might not eventually, and in the meantime why let the starred list get longer?
Academic review article on the risks of not breastfeeding for mothers and infants, and the role of obstetricians and hospitals in breastfeeding promotion. A very nice summary.
Via Empowering Birth blog, an informed consent roleplay. Has anyone ever used this with a class? It seems like a great idea to get people prepared to actually advocate for themselves - it's easy to talk about it beforehand, and harder to actually do in the moment.
And another link from Enjoy Birth about choosing hospitals wisely.
A dad talks about his thoughts on breastfeeding.
At Guerilla Mama Medicine, HUGELY important questions and thoughts about race and the natural childbirth movement.
An article from RH Reality Check about The Doula Project, which provides doulas for women who are having abortions and who are relinquishing their babies for adoption. I'm proud to say that I know one of the co-founders, Lauren Mitchell, who has an awesome quote in the piece: "You can't speak for your client, even if what's going on is the opposite of what she wanted - you're not in control of the room. But you are in control of what you are giving your client, and that is an informed ally and a deeply empathetic presence. When you're a doula you have to acknowledge how to be 'human' even when you want to be more than that. What keeps me going is the feedback from the clients that the space that I've created for them is unique and extremely important." If I end up back in NYC I would LOVE to volunteer with them!
From Birth Sense, thoughts about manual rotation of the fetal head. I have seen this happen once, and it was very effective - baby went from making very little progress with pushes, to crowning within minutes. But the midwife writing the article reminds us that it's also extremely important to move the mother!
I've also been enjoying Birth Sense's series, "Your Doctor or Midwife Still Does WHAT?" Here's a sample: #5, Cervical Exams. Reading expectant mothers' blogs I come across so many sighing with frustration that they're still not dilated at all, when is this baby going to come, etc. etc. Since there are very few actual medical reasons to do a cervical exam, it starts to seem like a highly effective method of psychological priming for induction.
Navelgazing Midwife did a great series of photo posts called "Teachable Moments" about placentas, vernix, trailing membranes, etc. Here's a great one on being born in the caul. I guess I should put in a disclaimer that these photos involve vaginas and birth fluids and stuff like that, although I have such a high tolerance at this point I have to remind myself that somebody else might need a warning.
That's all for now - off to watch me some Olympics!
Monday, October 19, 2009
Which is more important: your birth plan or your provider's?
The Unnecesarean has a new post up, reposting a mother's copy of her OB's birth plan. (He handed it to her husband at the 26-week visit.) Here are some choice excerpts:
* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.
* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.
* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.
So much of what this guy has written is distorted or just plain wrong, it's incredibly paternalistic, and violates basic legal rights (the decision to perform a c-section is at his discretion? Um, actually it requires signed consent forms. Signed BY THE PATIENT.)
And I kind of love it. Why? Because it's honest and lays it all out. In the end, your care provider's birth plan carries a lot more weight in the hospital than yours does. This guy isn't kidding about rupturing your membranes at his discretion; at the extreme end of things, he can tell you he's "just going to do a vaginal exam" and then rupture them without ever asking you, and that piece of paper in the corner saying you want to wait until your water breaks spontaneously isn't going to protect you. Even a doula, your partner, or a committed nurse can only do so much ("Whoops! I guess they just ruptured by accident!") And that's why I would say it's more important to get your care provider's birth plan than it is to give them yours. I've said before that if you find the right care provider and birthplace, you don't need a birth plan, and that's because you have found a care provider and learned enough about THEIR birth plan to know that it matches what YOU want.
The mom who posted her OB's birth plan ended up running so far in the opposite direction that she ended up at a birth center with a midwife and was delighted with her choice. But let me say - as some of the commenters on the Unnecesarean were pointing out - that this isn't an argument for women just needing to choose different care providers. This guy is an honest jerk with non-evidence based practices, but he's still a jerk with non-evidence based practices (say that 10 times fast!), there are more out there, and many women don't have the choice to find a new provider. At the individual level yes, PLEASE, find out your care provider's birth plan and make a switch if you need to. But on a bigger level, we need to stamp this stuff out.
Because, seriously, "Delaying [cord clamping] is not beneficial and can potentially be harmful to your baby" - as one of the commenters to the original posting said, this birth plan would be modern obstetrics only if it were written in 1975.
* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.
* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.
* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.
So much of what this guy has written is distorted or just plain wrong, it's incredibly paternalistic, and violates basic legal rights (the decision to perform a c-section is at his discretion? Um, actually it requires signed consent forms. Signed BY THE PATIENT.)
And I kind of love it. Why? Because it's honest and lays it all out. In the end, your care provider's birth plan carries a lot more weight in the hospital than yours does. This guy isn't kidding about rupturing your membranes at his discretion; at the extreme end of things, he can tell you he's "just going to do a vaginal exam" and then rupture them without ever asking you, and that piece of paper in the corner saying you want to wait until your water breaks spontaneously isn't going to protect you. Even a doula, your partner, or a committed nurse can only do so much ("Whoops! I guess they just ruptured by accident!") And that's why I would say it's more important to get your care provider's birth plan than it is to give them yours. I've said before that if you find the right care provider and birthplace, you don't need a birth plan, and that's because you have found a care provider and learned enough about THEIR birth plan to know that it matches what YOU want.
The mom who posted her OB's birth plan ended up running so far in the opposite direction that she ended up at a birth center with a midwife and was delighted with her choice. But let me say - as some of the commenters on the Unnecesarean were pointing out - that this isn't an argument for women just needing to choose different care providers. This guy is an honest jerk with non-evidence based practices, but he's still a jerk with non-evidence based practices (say that 10 times fast!), there are more out there, and many women don't have the choice to find a new provider. At the individual level yes, PLEASE, find out your care provider's birth plan and make a switch if you need to. But on a bigger level, we need to stamp this stuff out.
Because, seriously, "Delaying [cord clamping] is not beneficial and can potentially be harmful to your baby" - as one of the commenters to the original posting said, this birth plan would be modern obstetrics only if it were written in 1975.
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