Wednesday, April 17, 2013

Contradiction in Obstetrics

Good Morning.
As I put the finishing touches on my curriculum, set to be published with the month, I have been doing some additional research.  While not terribly surprising to me, I still can't help but notice a stark contradiction in two specific areas of maternity care that I want to draw attention to.
The link below titled "Consumer Reports"will connect to to an article I found on the Washington State Healthcare Authority web page:, for your reference.  In this article, they are discussing the dangers of:

  1. Elective early delivery (induction)
  2. Elective Induction with a low risk pregnancy
  3. C-Section with Low Risk first birth
  4. Automatic second Cesarean Section
  5. Late ultrasound (after 24 weeks)
  6. Continuous Fetal Monitoring
  7. Early epidurals
  8. Routine Rupture of Membranes
  9. Routine Episiotomies
  10. Sending your newborn to the nursery
Consumer Reports

They spend time in the beginning discussing Cesarean, which all but the last of the above interventions lay a breadcrumb path to. Every single one, and I would add: Routine use of IV fluids and staff who offer and offer and offer drugs like a pusher. 
In the article they also mention that "knowledge is power" and talk about how women should be informed.  Now, you all know that I am an advocate of being informed, and frankly the odds of walking into the hospital without quite a bit of information or having formed any kind of opinion on all of these above interventions, and walking out having avoided the big 10 above....not to mention the Cesarean Section at the end of the breadcrumb trail, I would conservatively place at 0.00% I am also an advocate of making sure they know you are informed by writing a birth plan.   This brings me to the first contradiction.  As I was finalizing a few chapters this week I realized that I needed to find a quote that eluded to being prepared; writing a plan.  I spent several hours looking for just the right quote, and in the process I sifted through pages and pages of quotes (blog entries and responses) written by nurses that made my head spin.  The website is called  I wasn't sure if these ladies realized that you don't actually have to sign in as member to read through these posts.  The specific thread I was reading referred to a "hilarious birth plan".  It was written by a woman who was clearly just fine with all of the above interventions, with or without cause.  It was a snarky piece written to devalue, undermine, and degrade women who have any preferences at all for their birth experience.  The nurses thought it was a hoot, often stating that they were going to print it out and hang it in the break room.  Some chimed in saying that their OB would LOVE THIS and that he/she refuses to work with women that bring in a birth plan altogether. Here are a few of the lowlights:

LOved that birthplan!! We always groan when someone comes in with a birth plan, or as we call them.... "KOD" the Kiss of Death. 

Oh that was soooo funny! I'm going to print it out for my OB professor to read to class. She'll love it!

Funny as hell! I am printing that and taking it to work with me to show my co-workers! At least this plan actually HAPPENED. When I see a birth plan I usually start getting the c-section papers stamped up and ready to go b/c you know that is what normaly happens with those darn birth plans!

loved this birthplan!!!! where was this lady when I was working L&D? it got so that when people mentioned that they had a birthplan, I had to consciously supress a groan.......... (and then go stamp the c-sec papers just in case)

I work with a Doc who hates birth plans. In fact, he tells his patients who come to him with a birth plan, to hit the road. Up front, he tells them he cannot be their doctor.
I think, even he, would like this birth plan.

There were a few supportive responses, this was my favorite.  Balanced, intelligent, and fair.

I've read quite a few birth plans and this was hilarious!!! Definitely got a good laugh out of it. 

It's just sad that serious birth plans seem to be a ticket to the OR. I've never thought of a birth plan as strictly for the nurses though. I think it should be something for the provider. With my first baby, I asked my midwives about a birthplan and they said it wasn't needed b/c they "were my birth plan."

I was fast-tracked into a c-section.  If a woman wants a birth plan and their doctor or midwife is opposed to it, that should be a sign for them!

The second time I had a birthplan with a list of bulletpoints - a "long" one for my new midwives and a short one for the hospital. I didn't expect the nurse to read and digest it as much as I wanted to remind my midwife, doula and dh of what I wanted. Maybe that's why it was successful and I didn't end up back in the OR? Who knows! At any rate, I did make bullet points for things that I wanted that might not be the "typical practice" in the hospital. I didn't want someone walking in every 5 minutes asking when I was going to get my epidural. I would ask for my myself if that's what I wanted, thank you! I didnt' want my nurse coaching my pushing with counting. I didn't have an epidural so I could feel the urge. I did consent to have my water broken after 36 hours of labor but that was about it for interventions.  The homebirth thing is a good point though - unfortunately it's illegal for midwives to attend homebirth vbacs in my state and not all insurances will cover homebirths and/or CPMs (who are more likely to offer homebirth). I DID have a birth plan for a c-section also and a birthplan for a still birth or neonatal death as well. My old hospital took my first baby to the (regular) nursery while I was in recovery and I wanted the baby with me the second time. I did ask the hospital about that ahead of time and they just said to let them know.

I am so frustrated by the negativity and the condescension and I am 100% certain that it contributes to the KOD mentality and ultimately to the outcome of births.  If your nurse has already decided that you are a harpy because you have ANY opinion, she is less likely to go to bat for you, she may have already filled out the paperwork for your cesarean and may unconsciously have become personally invested in that being the outcome, and they have the nerve to talk about trying to control the birth; Hi Pot, I'm Kettle......Hypocrite. She has already placed you in a box, a box filled with women that have written birth plans before.  They may have asked for irrational things, they may have been combative in their presentation, they may have been rude.  I'm sure nurses may have seen a great variety of birth plans, sometimes un-informed women printing whatever they find off the web, not necessarily even knowing what they are requesting, sometimes very short, stating only very specific concerns, like drug allergies or a fear of needles.  At times they may be too detailed, giving the impression of having an opinion about everything, or a woman who is too controlling, un-trusting, afraid, paranoid.  None of that really matters though.  The job is to nurse them, whatever their needs are.  Policies and protocols are one size fits all, we are not.  The idea that a woman who plans her birth causes her own cesarean is as stupid as it gets.  The belief that this is the case is more likely to blame.  While a woman who is wound up, trying to control EVERY aspect of her birth experience may be too tense to allow her baby to move easily through the perineum, that same woman may have been training to relax her pelvic floor muscles with the same fervor that she used to write her plan. You are making very broad, sweeping, unfair, suppositions. If a labor is un-eventful, uncomplicated, and is not requiring the nurse to constantly monitor the FHR or the Maternal blood pressure, is it really too much to ask that we instead use your presence to create the birth she desires, how close can we make to to her ideal birth?  Are you incapable of changing a play list if your hands aren't obsessively assaulting her cervix checking her for cervical change (making it impossible for her body to relax enough to dilate)?  When did sitting at the computer, clicking this and that and asking the same question a thousand times while looking at a print out from the external monitor become nursing?  How has "taking care" of her become beneath you? Sorry for the rant.  I have seen the TWILIGHT ZONE difference between an normal birth outside of a hospital and what they consider to be a "normal" birth inside those walls too many times. 
* I have worked MANY times with wonderful nurses, so I don't mean to imply that all share this attitude.  In my experience, the KOD crew outnumbers the true nurse by a large margin.

On the the next contradiction.

If the Washington State Healthcare Authority has set a statewide goal of a cesarean rate of less than 20%, why do the "best", most technologically advanced, most expensive medical centers, with the highest acclaim in the area have a rate of almost double that?  Are they unaware of the goal? Are they incapable?  Are they trying to make money at the risk of over-treating patients? Are they trying to be too politically correct and giving in to women who want a cesarean because they are tired even after only 16 hours of labor (happened yesterday at Evergreen)? 16 hours we have not even reached average yet.  Are they trying to keep their surgical skills sharp?  Are they causing cesareans with the over use of the top ten listed above?  Are they creatures of habit?  Are they too industrialized? Are they telling themselves stories that rationalize the practices? Are they just trying to satisfy the shareholders expectations for profit? In my humble opinion...Yes to all, at some level.
What other conclusion could there be?
If you don't want a Cesarean, please make sure that you choose the Hospital that you go to (whether planned or on transport from a home birth or free standing birth center) VERY wisely.  Be willing to travel for that additional 10% of a chance that you may deliver vaginally.  The building and birthing suite may not be as pretty, but the saying "don't judge a book by it's cover" it very important in this situation.  The values of those you trust with your care will matter as much as the circumstances that may come up during your labor.  If you can't find a provider or a hospital with a cesarean rate of less that 30%, HIRE AN EXPERIENCED DOULA. Do not rely on the nursing staff to be your advocate if it involves contradicting the OB.  They will advocate for you with your family and friends, but rarely will a nurse undermine her overseer.

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