What choices did you make for L&D?

Jolie, BSN · May 8, 2005

As a doula and as someone about to take her LVN exam, I've had the oppurtunity to see many docs and nurses in action in the cities I've lived in. For this pregnancy, I ended up choosing a homebirth with a CPM who is experienced and well respected. She has great stats, a low transfer rate (though not low enough to make me nervous that she's risking client/baby health) and a wonderful approach to prenatal care. My appointments last over an hour, and she travels to my home for prenatals. We do any blood and urine work we need to in my home as well. It's been a fascinating experience. My husband is usually the one to find the heartbeat with both the fetascope and the Doppler, and my little boy has also learned to hear the baby's heartbeat and assess fetal position (not bad for a 6 year old! :) ) We focus a LOT of nutrition, too, which is an intervention known to prevent birth and postpartum complications, as everyone here knows.
I guess I just saw enough clients with great intentions walking into hospitals and getting really poor, non-evidence based information that I got worried about what might happen for my own birth. My first was born in a hospital, however, and I had a couple of wonderful nurses. I also had a doula, and she was married to my doc, so right there you know he had an awareness of normal birth.
As for those docs who would choose a c/s over a bad tear, well, many of them have CAUSED the tears they're talking about, either through poor management of the head delivery, not insisting on upright second stage pushing or clipping an episiotomy and then being suprised when there's a fourth degree tear! (Ooops ... :angryfire )
So anyway .... those were some factors I considered when choosing a provider for my birth.
Alison

Alison,

I'm curious as to how non-nurse midwives handle some of the aspects of pre-natal care. How do they obtain and administer medications such as Rhogam, order pre-natal labs and groupB strep testing, and have IV supplies and resuscitation drugs available to them, when these items typically require a prescription?

I worked in the Carolinas about 15 years ago, and saw a number of non-nurse midwife patients dropped off at our hospital when things went wrong with home labors. Non-nurse midwifery was illegal there at that time, and so we never saw or knew who the midwives were. They literally dropped their patients and ran. We were left to care for dazed and confused parents with no pre-natal records. It was incredibly difficult, and left me with a very bad taste in my mouth for these providers who refused to stand up and accept responsibility for their actions. I know that does not hold true for every non-nurse midwife, but I am still curious as to how they go about providing scientifically sound care to their clients without the advantage of hospital affiliation, prescriptive authority, and physician back-up.

jennobrn01 · May 10, 2005

"I got to watch the whole thing in the reflection on an overhead lamp.....to see one's own csection, well is a trip. I am glad I could."

OT:

That is so funny... I did the same thing....though I didn't notice the reflection until the MD and first assist. started closing. They were like two old ladies at a quilting talking about suture material and techinique. What an odd experience to watch without feeling.

peds4now, RN · May 10, 2005

I'm still in school, but the lack of respect as a human being, acknowledgement of my right to make my own medical decisions, and the lack of coherent, evidence-based care I received in labor and delivery for some of my 5 hospital births really moved me to become an RN. Only one doc ever listened to my wishes, and I have to say some of the nurses seemed completely disoriented to walk in on something other than the "heavily medicated and confined to bed" script. But the flexible, knowledgeable RNs who worked with me instead of as if I didn't exist, and who reminded the docs what I wanted made such a difference! I asked for/insisted on:

That I be consulted and given enough information to give/withold informed consent for absolutely every procedure unless there were an immediate, life-threatening emergency.

laboring at home a while

3-5 minutes doppler/hour after initial strip

no AROM until full dilation

no IV unless strep B +, removal immediately after antibiotics if yes

no drugs for pain unless giving stitches

food and drinks as I wished (which I didn't anyway)

using the toilet

staying mobile until I couldn't move anymore

choosing my delivery position

no epi

no Pitocin postpartum sans abnormal blood flow (i.e., not routine)

At least some of my wishes were always disregarded without medical indication or even asking my persmission with each labor, which is why I chose to have one child at home. The worst was when 3 nurses physically forced me from an all-fours pushing position to flat on my back "so we can see what's going on" even though I was yelling no! But once I'd done that I was more confident/comfortable in the hospital, and had 2 more children in hospital. That said, I don't think I'll want to work in l&d. I don't want to be in a position where I have to follow protocols that I think are not evidence-based or humiliating with patients who are not even sick/injured.

SmilingBluEyes · May 10, 2005

I'm still in school, but the lack of respect as a human being, acknowledgement of my right to make my own medical decisions, and the lack of coherent, evidence-based care I received in labor and delivery for some of my 5 hospital births really moved me to become an RN. Only one doc ever listened to my wishes, and I have to say some of the nurses seemed completely disoriented to walk in on something other than the "heavily medicated and confined to bed" script. But the flexible, knowledgeable RNs who worked with me instead of as if I didn't exist, and who reminded the docs what I wanted made such a difference! I asked for/insisted on:
That I be consulted and given enough information to give/withold informed consent for absolutely every procedure unless there were an immediate, life-threatening emergency.
laboring at home a while
3-5 minutes doppler/hour after initial strip
no AROM until full dilation
no IV unless strep B +, removal immediately after antibiotics if yes
no drugs for pain unless giving stitches
food and drinks as I wished (which I didn't anyway)
using the toilet
staying mobile until I couldn't move anymore
choosing my delivery position
no epi
no Pitocin postpartum sans abnormal blood flow (i.e., not routine)
At least some of my wishes were always disregarded without medical indication or even asking my persmission with each labor, which is why I chose to have one child at home. The worst was when 3 nurses physically forced me from an all-fours pushing position to flat on my back "so we can see what's going on" even though I was yelling no! But once I'd done that I was more confident/comfortable in the hospital, and had 2 more children in hospital. That said, I don't think I'll want to work in l&d. I don't want to be in a position where I have to follow protocols that I think are not evidence-based or humiliating with patients who are not even sick/injured.

Nothing you requested is unreasonable or wrong. I am so sorry your wishes were so callously disregarded and your treatment unfair and unwarranted. Consider, you could be an advocate for people just like yourself, upholding their wishes as much as humanly and reasonably possible in the hospital setting. You could make a HUGE difference as an OB nurse, you know? Something to think about.

Personally, I would never behave the way you describe above. And that is NOT just me. (((Hugs))) and best wishes, wherever your career takes you.

hillaryd · May 12, 2005

I find it fascinating to read all these stories. I'm a student nurse that plans to continue on to earn my CNM. My decision was based on not only the birth of my 2 girls, but also as playing childbirth coach at a few friends' deliveries.

My first daughter I used my FP as an OB. I'm sure some of his reluctance to pay any sort of attention to me was due to the fact that I was 17 at the time, but for heaven's sake I was the patient. I had to fight kick and scream (literally at times) to keep my daughter's birth as my own. I wanted no intervention, natural childbirth if at all possible. I had read everything I could get my hands on about the matter, and feel I my decision was an educated one.

The battle started two weeks before my due date. He wanted to induce me because I was "too small". I asked why he said that, and he said that no one my size could deliver a full term baby. Now, my tummy was HUGE, as I am only 5'2" and there is no where for the kid to go but out! While the idea of not being pregnant anymore was pleasant, I wasn't dilated/effaced at all and my daughter hadn't dropped one bit, so I declined. The next week, same story. Week of my due date, same story, except this time with my lovely doctor telling me horror stories to try to scare me into it. On top of that, while waddling through the hall after my appointment I hear him talking to a nurse about how he has this patient that just won't let him "pit and cut" (which I assumed was 'pitocin and c-section'). I don't know that he was referring to me, but I took offense. Actually, I hope more than one pt was giving him grief over it!

One week post-edd, the dr tries telling me that the baby could be in distress because she was "so late". I asked to have a NST to see if she was OK, and he huffed "Never mind, it isn't necessary." (Leading me to believe that again, I was just inconveniencing his schedule).

10 days post-edd, I had a scheduled appointment. Lo and behold I was in labor, 3cm and 75% eff. I don't know what station she was at, but she had definitley dropped as I could breathe again .

At the hospital, same story. Dr wanted AROM, I said no; wanted pit drip because he "has dinner plans at 6 and doesn't want to miss the birth" (don't get me started on this charming statement); to top it off, the L&D nurse I had apparently wanted a drugged incoherant pt as well, as she asked me every half hour if I was ready for my epi yet. I persevered, and by the time I broke down and asked for drugs I was well into transition so it was too late. While pushing, I started complaining about my back and the nurse told me to try all 4s...I did, briefly, but realized that felt even worse (thinking of a certain scence from the Alien movie here). When I didn't stay down she pushed me into that position. My mom swears I took a swing at her; I don't remember that. I know I demanded that she not be allowed in the room, and screamed at her to GET OUT the next time I saw her.

The end result, I had a healthy, normal, non-intervened (is that a word?) baby girl weighing in at 9#5.5. The dr said if he'd have know she was that big he'd have never 'let' me go full-term.

My second daughter, I had a CNM who practices with an OB/GYN and the difference was night and day. I had a NST at 10 days post-edd. I was never asked to be induced (AROM, pit, or otherwise), the hospital experience was wonderful (they let me eat! another source of battle with my first). My mw even called ahead to the hospital once I was ready to go to make sure I had a nurse comfortable with non-intervention L&D. I did have a few complications, but nothing major. My 2nd started face-up, then after pushing for a couple of minutes backed herself up and turned around, and after she was born I bleed pretty heavily, but a shot of methergine took care of that. At no point did a doctor come in to 'fix' things. This child was tiny at 8#9.5

This post has gotten long. I know there are good doctors out there, and I have probably experienced complete opposite ends of the spectrum, but the fact remains that had I not educated myself, who knows what might have happened with my first birth. She is now 9 years old, healthy, and suffered no ill-effects at the hands of the delivery; likewise, my younger (4yo) is the same. The difference is how I remember bringing each of them into the world. With my 1st, I had to fight to keep control of MY delivery, with my 2nd it was never a question. My mw even said that she wasn't there to deliver the baby--that was my job. She was there to help me along every step of the way. In L&D, the nurse assigned to me kept that theme--she never said "I'm doing this..." She alwasy said "I'm helping you to..." It's a small difference, but one that makes a huge difference to the most important person in that room--the patient!!

I'm sorry I rambled on so much about this. It's something that is very important to me, and I hope that I do well as a nurse and a midwife to provide the kind of well-informed, calm birthing experience that I had with my 2nd daughter.

Counting my girls, I've already 'delivered' 3 babies...2 of them my own and one of my best friend who said she had to push--tried to get her to do shallow breathing until someone (anyone) professional could get in the room...apparently she couldn't wait and asked me if she was feeling the head. I looked, and sure enough there was Hannah poking through. My friend's mom ran to find a nurse or dr and when they finally (and by finally I mean probably 30 seconds later) I was standing there with a very bewildered look on my face holding a slimy screaming baby girl! If only all births were that simple

jdkaos · May 13, 2005

I find it fascinating to read all these stories. I'm a student nurse that plans to continue on to earn my CNM. My decision was based on not only the birth of my 2 girls, but also as playing childbirth coach at a few friends' deliveries.
My first daughter I used my FP as an OB. I'm sure some of his reluctance to pay any sort of attention to me was due to the fact that I was 17 at the time, but for heaven's sake I was the patient. I had to fight kick and scream (literally at times) to keep my daughter's birth as my own. I wanted no intervention, natural childbirth if at all possible. I had read everything I could get my hands on about the matter, and feel I my decision was an educated one.
The battle started two weeks before my due date. He wanted to induce me because I was "too small". I asked why he said that, and he said that no one my size could deliver a full term baby. Now, my tummy was HUGE, as I am only 5'2" and there is no where for the kid to go but out! While the idea of not being pregnant anymore was pleasant, I wasn't dilated/effaced at all and my daughter hadn't dropped one bit, so I declined. The next week, same story. Week of my due date, same story, except this time with my lovely doctor telling me horror stories to try to scare me into it. On top of that, while waddling through the hall after my appointment I hear him talking to a nurse about how he has this patient that just won't let him "pit and cut" (which I assumed was 'pitocin and c-section'). I don't know that he was referring to me, but I took offense. Actually, I hope more than one pt was giving him grief over it!
One week post-edd, the dr tries telling me that the baby could be in distress because she was "so late". I asked to have a NST to see if she was OK, and he huffed "Never mind, it isn't necessary." (Leading me to believe that again, I was just inconveniencing his schedule).
10 days post-edd, I had a scheduled appointment. Lo and behold I was in labor, 3cm and 75% eff. I don't know what station she was at, but she had definitley dropped as I could breathe again .
At the hospital, same story. Dr wanted AROM, I said no; wanted pit drip because he "has dinner plans at 6 and doesn't want to miss the birth" (don't get me started on this charming statement); to top it off, the L&D nurse I had apparently wanted a drugged incoherant pt as well, as she asked me every half hour if I was ready for my epi yet. I persevered, and by the time I broke down and asked for drugs I was well into transition so it was too late. While pushing, I started complaining about my back and the nurse told me to try all 4s...I did, briefly, but realized that felt even worse (thinking of a certain scence from the Alien movie here). When I didn't stay down she pushed me into that position. My mom swears I took a swing at her; I don't remember that. I know I demanded that she not be allowed in the room, and screamed at her to GET OUT the next time I saw her.
The end result, I had a healthy, normal, non-intervened (is that a word?) baby girl weighing in at 9#5.5. The dr said if he'd have know she was that big he'd have never 'let' me go full-term.
My second daughter, I had a CNM who practices with an OB/GYN and the difference was night and day. I had a NST at 10 days post-edd. I was never asked to be induced (AROM, pit, or otherwise), the hospital experience was wonderful (they let me eat! another source of battle with my first). My mw even called ahead to the hospital once I was ready to go to make sure I had a nurse comfortable with non-intervention L&D. I did have a few complications, but nothing major. My 2nd started face-up, then after pushing for a couple of minutes backed herself up and turned around, and after she was born I bleed pretty heavily, but a shot of methergine took care of that. At no point did a doctor come in to 'fix' things. This child was tiny at 8#9.5
This post has gotten long. I know there are good doctors out there, and I have probably experienced complete opposite ends of the spectrum, but the fact remains that had I not educated myself, who knows what might have happened with my first birth. She is now 9 years old, healthy, and suffered no ill-effects at the hands of the delivery; likewise, my younger (4yo) is the same. The difference is how I remember bringing each of them into the world. With my 1st, I had to fight to keep control of MY delivery, with my 2nd it was never a question. My mw even said that she wasn't there to deliver the baby--that was my job. She was there to help me along every step of the way. In L&D, the nurse assigned to me kept that theme--she never said "I'm doing this..." She alwasy said "I'm helping you to..." It's a small difference, but one that makes a huge difference to the most important person in that room--the patient!!
I'm sorry I rambled on so much about this. It's something that is very important to me, and I hope that I do well as a nurse and a midwife to provide the kind of well-informed, calm birthing experience that I had with my 2nd daughter.
Counting my girls, I've already 'delivered' 3 babies...2 of them my own and one of my best friend who said she had to push--tried to get her to do shallow breathing until someone (anyone) professional could get in the room...apparently she couldn't wait and asked me if she was feeling the head. I looked, and sure enough there was Hannah poking through. My friend's mom ran to find a nurse or dr and when they finally (and by finally I mean probably 30 seconds later) I was standing there with a very bewildered look on my face holding a slimy screaming baby girl! If only all births were that simple

Congrats to you. I love to do deliveries with informed pts. If they want no interventions, I listen to them. The key here is educated!! When something does go wrong, I have to intervene. If the pt. wants NO interventions, then they should deliver at home. If they are at the hospital I have no choices, my hands are tied. Please pass that along to your pts. as you gain your CNM.

FrumDoula · May 13, 2005

Congrats to you. I love to do deliveries with informed pts. If they want no interventions, I listen to them. The key here is educated!! When something does go wrong, I have to intervene. If the pt. wants NO interventions, then they should deliver at home. If they are at the hospital I have no choices, my hands are tied. Please pass that along to your pts. as you gain your CNM.

First off, if a patient wants very minimal or no interventions at a hospital, it is well within their right to refuse any routine intervention. That's part of the patients bill of rights as I understand it. If something goes wrong, that's what medical staff and equiptment are there for, and the patient can help make choices and be heard as things go along, provided it is not emergent and/or the patient is incapacitated.

As far as a homebirth goes, plenty of us who homebirth still have interventions. We do vag exams, we are monitored in and out of the water, etc. Heck, herbs are interventive, too. Monitoring is simply good safe care, and most homebirth midwives and docs I've met hold to ACOG policies on monitoring. Also, if something goes wrong, and there's a need for it, it's not like we sit on our hands doing nothing. There are interventions, up to and including transfer of care, which are appropriate, and which the midwives outline with their clients before the birth. If they're piss poor midwives, maybe they don't, but heck, I've seen piss poor practitioners at every level, so I try not to target midwives for that.

I think the most important thing for helping to ensure a positive memory for the woman, as well as helping to prevent PTSD after the birth, is to make sure she's involved in decision making as much as possible and is heard throughout. Women can be made to feel like garbage with "optimal" births, or they can come out feeling terrific even after a highly medicalized, interventive birth. Penny Simkin did an interesting retrospective study on this very subject that was written up in Birth.

I just hate hearing stories like the one earlier, about patients coerced and guilted into action. Give them all the info and answer their questions. If they're clueless and unwilling to take responsibility, then you have to guide them more, obviously. But guilt and coercion are inappropriate tactics to use, IMO.

I remember one amazing L&D nurse I met when I was having a miscarriage in a hospital. I was gunning for a D&C, but she took the time to explain my options to me and to help me deal with the whole thing. I ended up leaving the hospital and having the miscarriage at home, sans D&C. I'm glad she took the time to introduce that option, because I count it as something that was, while not happy, a positive experience, weird as that may sound. (And I ended up having a D&C years later with another miscarriage and had many more complications due to a retained placental fragment.) I was so grateful to that nurse. I doubt I'll ever forget her. She presented everything in such a respectful way.

Alison

hillaryd · May 13, 2005

I remember one amazing L&D nurse I met when I was having a miscarriage in a hospital. I was gunning for a D&C, but she took the time to explain my options to me and to help me deal with the whole thing. I ended up leaving the hospital and having the miscarriage at home, sans D&C. I'm glad she took the time to introduce that option, because I count it as something that was, while not happy, a positive experience, weird as that may sound. (And I ended up having a D&C years later with another miscarriage and had many more complications due to a retained placental fragment.) I was so grateful to that nurse. I doubt I'll ever forget her. She presented everything in such a respectful way.

Alison, I'm glad that you were given the options that involve keeping your situation in the privacy of your own home. That sounds like an excellent nurse who really does understand the needs of her pts.

I also wanted clarify--there are 'no interventions' and then there are 'NO interventions' (meaning, if mom and baby are both to be healthy then God Himself had better fly in the window). When I say 'no interventions' I mean no unnecessary interventions. Monitoring is important; checking for GD and Rh issues is important; having a completely pain-free birth between the hours of 9 to 5--eh, not so much.

I feel my biggest struggle will be tolerating (with at least well-feigned respect) the decisions of the moms who walk into the hospital barely contracting and demanding an epi, or the ones who don't even want to give BF a fighting chance, etc. It'll be interesting to see how I learn to cope with this...I might be as bad as the RNs who stress if their laboring moms aren't drugged up and sleeping through the process! (just kidding...I hope I'm a bit more professional than that)

MommyJoy · May 16, 2005

What was your birth like? Did you hand pick your providers? Were you set on having a lady partsl delivery...? Would you have been ok with a section? Did you want an epidural or unmedicated birth?
I have met ob's who said they would happily take a planned section due to the horrible tears seen at vag. deliveries. So, my biggest question is, how did being a maternity nurse effect you decision making as a patient?

My husband and I had all thre of our children at the same wonderful hospital. My nurses were great and had a huge impact on my decision to become a nurse. I delivered our first child at 27. The doctor that did my pre natal care, delivered all three babies, post natal care, has been my doctor since I was 8 yrs. old. He did it all, and I think he is the greatest.

My family has moved to a different state, but this man is still my doctor. Of course my kids have a local pediatric doctor. But when it is time for my yearly checkup, I will travel back to KS.

hillaryd · May 16, 2005

My husband and I had all thre of our children at the same wonderful hospital.
My family has moved to a different state, but this man is still my doctor. Of course my kids have a local pediatric doctor. But when it is time for my yearly checkup, I will travel back to KS.

MommyJoy--what hospital? I'm in the KC area; my first was delivered at Olathe Medical and my second at St Luke's South.

nancimarie · May 24, 2005

I became a OB nurse after having my four kids, I think it would be a wonderful experience to go through labor with everyone I work with now. I would know more what to expect out of people and I know their personalities better.

What was your birth like? Did you hand pick your providers? Were you set on having a lady partsl delivery...? Would you have been ok with a section? Did you want an epidural or unmedicated birth?
I have met ob's who said they would happily take a planned section due to the horrible tears seen at vag. deliveries. So, my biggest question is, how did being a maternity nurse effect you decision making as a patient?