labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Sunday, October 26, 2008

Knowledge is Power

On line with my previous post regarding knowledge of the birth process in the hospital, and just knowledge of normal birth in general, or even knowledge of what specific events have occurred during their own birth- I'm amazed at how little people know.

When I meet people, my profession frequently comes up in conversation. And this leads into various birth stories, doctor stories, nurse stories, midwife stories, medical problems. Just recently I met a couple who had a baby just days before. They were very excited to discuss the details of the labor and birth, and from what I gathered by what they were telling me, it became very obvious they really didn't know what was going on and why certain things were happening. They said they were threatened with a c-section because the woman's heart rate bottomed out requiring oxygen. The baby needed to be cared for by a NICU nurse in the regular nursery because they had to suck out the nose at birth.

For those who are labor nurses or midwives, or some other person working in the birth arena, know that neither of these things were the reason a c-section was "threatened" nor that a NICU nurse was needed to care for their baby.

How many people have a total misunderstanding of what occurs in birth, or specifically their own birth?

I think we (birth care providers in general) totally miss the boat on educating people on what is going on. Perhaps we assume that what we are explaining (if anything at all in some cases or places) makes perfect sense to those we are caring for when in fact they are not understanding or misunderstand the information. On the other hand, I've seen plenty of people not bothering in trying to educate themselves or be assertive in their care because "the doctor/midwife/nurse is the professional and knows what to do/what should happen/what I need..." the list goes on.

In order to change the care in the maternity care system in our country, we need to educate the public better. We need to educate people what actually happens on labor and delivery units across this country, and not by the daytime tv shows sensationalizing how disaster is lurking just a breath away and how technology and medicine saves the day. We need to educate the public on the normalcy of birth. When people begin to understand what is routine in many labor and delivery units, people would start to buck the system.

I don't know how this could be possible, frankly. It seems like such a daunting task. There is a small subset of people in this country who do support normal birth and want to educate the masses- and are trying their hardest to do it- but there are gobs more of those who like the system just the way it is and have stronger, louder, and more expensive voices when dealing with the public.

I feel like I am rambling now, so I'll try to wrap this up. Bottom line: knowledge is power. And it begins with knowing what went on in your own birth, and then people can start to understand more and more about the system we have right now. I think once it's obvious that much of what occurs during birth in many systems and how it goes against the normal and natural process of birth, things can change.

Sunday, October 19, 2008

Birth Plans

Oh...birth plans. Frankly, I am not sure how I feel about them. I think they can be very useful in making sure your needs and wishes are communicated to those who care for you. But, on the other hand, they can be a barrier for those who care for you because they have this preconceived notion that birth plans=hippie, crunchy women who are resistive to medical care and think that you will inevitably end up with every intervention in the book before you have a c-section.

I have seen women who have very reasonable, flexible birth plans. Like, requests that pain medication or epidurals not be offered but if it is requested or asked about they are not opposed to receiving that type of pain relief; or requests that the baby be placed right onto mom's belly or chest at birth but are ok if baby needs closer assessment immediately at birth that requires the baby being taken to the radiant warmer/resuscitator.

And then I've seen very inflexible birth plans that request things like no fetal monitoring (absolutely impossible in the hospital) which basically ask for things that are better for a home birth. These types of birth plans I have no problems with in regards to what they want or not want, but often scratch my head wondering if these couples have taken into account that they are giving birth in a hospital. As much as I feel continuous fetal monitoring or even IVs are not necessary in every birth, some hospitals have environments, protocols, etc that don't "allow" for this. I really think those who want to avoid all interventions look into alternatives to birth sites because the second you step into a hospital you give up some things, like complete control. I wish this wasn't the case, and try very hard as a nurse to let women know about informed consent and choice, but there are very few hospitals I know of that go with any request a woman has.

What really gets me though, are birth plans that are so evident that the couple did absolutely no research on birth or hospital birth. For instance, I cared for a couple recently who had a 5 page birth plan. It was a birth plan that came from an website template, likely something where you just check off what you want to include on your written plan. And what they checked for what they wanted and not wanted completely contradicted itself in some fashion. Like this:

  • I do not want an IV
  • I want an epidural as soon as possible

Ok.... it was very evident that they did not do any reading or class on childbirth ed because epidurals require an IV. There is not an anesthesiologist in the world that would place an epidural without IV access. Not to mention that you need an IV fluid bolus in preparation for an epidural because a fairly common side effect of epidurals are low blood pressure; the IV fluid bolus helps to counteract a drop in blood pressure.

Or this:

  • Please do not separate me from my baby at any time
  • It is ok to give my baby a pacifier if crying while away from me

And this:

  • I do not want any students or residents caring for me

....when you are in a teaching hospital that has structured the care delivered by utilizing residents and involves other learners at varying degrees of involvement. Now, it is completely the woman's prerogative to not have learners involved in caring for them, but it seems a little weird to me that this woman would choose to come to a teaching hospital if she didn't want residents or students.

So I guess the bottom line is that I think birth plans can be a good thing if the couple has researched birth in the setting they will deliver as well as generally educate themselves on birth. But I can totally see why birth plans end up as fodder for negativity from care providers when it's plain as day that the couple has done no research on birth at all.

Monday, October 13, 2008

Vertex

Imagine all our surprise when the baby is pulled from the mother's abdomen from a vertex position during a c-section for breech.

First of all, I'd be pissed if I were that woman.

During my most recent shift at work (remember, I am still working as an RN) I was assigned to care for the scheduled c-section patient. Things during the prep were going along just smoothly, the woman and her husband were really responding to me and I found that the anxiety level they walked in with was soon next to nothing. During my prep, I asked the resident if she wanted to scan the woman to ensure that in fact this baby was breech. She said she would, asked if I would get the bedside ultrasound machine while she went to get the attending.

A few minutes later the resident said the attending felt it wasn't necessary; his Leopold's in the office the previous day along with an ultrasound at 37 weeks (she was 39 weeks now) confirmed the breech position. For a brief second I contemplated performing Leopold's maneuvers myself but decided against it as I didn't want to overstep my RN boundaries. The resident did them, however, and I could tell she was double checking herself...but she never said anything to me about what she was feeling.

And so all goes on without a hitch. When the doctors get to the uterus I always go around to watch- I find it fascinating watching a baby emerge via vagina or abdomen- and so I parked myself towards the foot of the surgical table. The resident reaches in to grab the fetal part in the pelvis and pull it through the incision. It's a head.

The room goes quiet.

Then as usual, baby is handing over to the awaiting baby nurse and pediatrician and the father goes over to the warmer to see his baby for the first time. Baby is taken to the woman and all goes well with the suturing and closing.

We then go to the recovery area, and things continue to go without a hitch. The woman feels well, the spinal working well for her pain, and her vital signs are stable. As I am assisting her with breastfeeding the baby for the first time, the attending and resident come in. The attending is more congenial than usual, and he's got a big smile on his face.

"Well!" he booms, "That baby must have done a last minute turn."

"What do you mean?" the husband asks.

"The baby was actually in a head down position," the attending answers.

Again, silence.

The conversation moves on and the attending continues to discuss the c-section; that in fact, it was perfectly fine that they did a c-section on a baby that was vertex because, well, the baby was a little on the big side (8lbs 6 oz) and her pelvis was "questionable". I knew the pelvis thing was grasping at straws because I had reviewed all the prenatal records when doing my nursing assessment and read the physical exam section. The doctor checked "gynecoid" under pelvis type- this is the most preferable pelvis type for childbirth. The baby's size would likely not have been an issue either, as many woman give birth to 8 pound plus babies. Not to mention that 8lb 6oz is not considered "macrosomia".

After a little more discussion between the patient, her husband, and the doctor they seemed ok. They were in the middle of being excited and overwhelmed of meeting their brand new baby. I continued my recovery assessments and said nothing about the vertex thing.

When the woman was about to be transferred to postpartum, the husband said to me, "So that c-section wasn't needed, was it?"

I paused. What do I say? I was conflicted. Do I try and support the doctor by saying something vague? Do I claim ignorance? Ultimately I decide to do best- tell it like it is:

"No," I say, "It wasn't."

The husband slowly nodded, taking in what I said.

Friday, October 10, 2008

It's Official...

....you may now call me Labor Nurse, CNM.