Would I be considered a "difficult patient?"

Specialties Ob/Gyn

Published

Okay, let me start by saying that I don't actually plan on birthing in a hospital again, and if I did, it would be because I risked out of homebirth, so the risk itself would probably make me more willing to compromise. So the question in my case is moot, but I have a lot of friends with the same desires.

I'm really just wondering if I came to your hospital as a healthy woman with an uncomplicated pregnancy and had these desires and a willingness to refuse the interventions to the point of signing off AMA, would I be labeled difficult or uncooperative. (Of course, with the disclaimer that if things became complicated to the point of danger to the baby, I would have no problem agreeing to intervention. For the purposes of this question, we're assuming all goes well).

- Heplock access, but no fluids. (I have bad veins, so the heplock is something I know is important for me.)

-Eating and drinking during labor, including herbal teas, such as red raspberry leaf and nettle tea.

-Intermittent monitoring with a dopplar. Initial twenty minute strip for baseline, but no monitoring with the actual fetal monitor after that. I would refuse the usual 15 minutes per hour rule.

-Complete freedom of movement. I would do whatever feels good and probably not ask first before bathing, squatting, etc.

-Initial lady partsl exam, but no others except at my request. I would refuse lady partsl exams offered or "required".

-I would not push at all until I had the urge, regardless of cervical dilation. (This is where refusing the lady partsl exams would work to my advantage).

-Hands and knees pushing position. I would absolutely not push in the semi-reclining or lithotomy positions.

-Immediate breastfeeding and no third stage pitocin. Baby in my arms for the first hour.

-I would refuse the hep B shot, vitamin K, eye ointment (I know I'd have to sign a waiver on that) and would choose to complete the pku at a health dept, rather than the hospital. I would require all newborn procedures to be done at my bedside, or I would refuse them.

-Discharge 12 hours after birth (or less) with the consent of the attending physician. (understanding that well established nursing, controlled bleeding, voiding, and urinating would all be prerequesites.)

Okay, that's my list. I really do want your honest opinions, and I don't mind at all if you would classify me as uncooperative. I'm willing to own the title if I earn it.

Thanks,

Sarah

You have every right to decide what interventions/treatments you want during birth. That does not make you difficult. I have been a labor/delivery nurse for many moons. Many of our interventions can cause more harm then good because they are utilized indiscriminately. I love it when Moms are informed and know what they want. You go girl!

While I appreciate the concern, and even the horror stories, I'm fully in support of homebirth and will be utilizing that option as long as my future pregnancies remain low risk and uncomplicated.

I do know all of the reasons for the interventions I am refusing are offered, and in some hospitals, required. I just don't agree with many of them. Take lady partsl exams, for instance. I do not agree that labor progress can be gauged by cervical dilation only, nor do I agree that women should be pinned down by someone's arbitrary idea of what "normal" labor progression is. To tell you the truth, the less I know about the state of my cervix during labor, the less anxious I am about how long it's taking! I am much more able to handle the pain than I would be if I had someone telling me every two hours that I had "only" dilated or effaced so much during that time.

Much of what we "know" in labor and childbirth is not known for very long. Evolution is the nature of the beast. Remember routine episiotomies? These were still common practice in many hospital five years ago. They ARE still common practice in some hospitals today, and yet the prevailing viewpoint now is that they are not only unnecessary for most women, but potentially harmful. While the shift may not occur for all of the interventions I mentioned, I do see nurses here who feel and practice the same way I do, so it can't be far off.

Th advice to have a face to face conversation with the nurses is a good one, as well as having the waivers in the chart. I know the medico-legal climate in this country is enough to make anyone working l&d think twice about straying from standard practice. Until standard practice changes, you will still get women in with their "demands".

Sarah

I wouldn't label you as difficult. Sounds like you are willing to keep an open mind.

i just have to tell my story. not all l&d nurses are so progressive. anything that is against hospital policy is frowned upon and becomes a liability no matter how antique the policy is.

when i was pregnant for the 4th time i knew from my own personal experience and my own readings and research what i wanted and did not want. right from the beginning with my ob i voiced my opinions. he said he did not have a problem with it but he did warn me that it was against the hospital policy therefore he could not guarantee me my wishes. i told him i understood however, i as a patient have a legal right to refuse.

when the day came i did refuse some interventions. the nurses tried to persuade me but i continued to refuse. although they did not say anything to my face their body language told me i was labeled a difficult patient. by the time i delivered i know they were glad to be rid of me.

in case you are curious this was a hospital that was delivering babies like they did 20 years ago. my wishes were to walk, have intermittant monitoring, no pitocin, NO enema and NO shave. believe it or not these were mandatory. they told me i was not allowed to walk, i had to be in bed with the continuous monitoring w/ iv pitocin and enema and shave were mandatory. i stood my ground and i am happy i did. after being monitored to make sure the baby was not in distress i got up and walked. my baby was born in a very short period of time without any drugs (no pit and nothing for pain).

sometimes you just have to make a stand. if you have a rationale for every step of your birth plan then i say go for it. you will probably be labeled but who gives a ****.

good luck.

I think home birth (with a well trained and sharp birth attendant) is great. I think that your choice to do home birth is a good one and think that your friends are probably better off doing the same.

If you came to my hospital I would probably ask you why you chose to come there if you didn't want any of the things we do there done.

I agree with allot of what you have in your birth plan.

If your not getting an epidural and not planning on using pit to augment, vag exams aren't needed other then to decide when to call the doc or begin pushing. Any nurse that has labored a few dozen non epidural patients can tell what your cervix is just by watching you.

As for moving around, thats great. love it when patients walk around or use the jacuzzi.

As long as you are well hydrated and taking good p.o. fluid a hep lock would be sufficient.

Eating and drinking would be fine with me (I wish they would change our policy at work)

I would have trouble with a few of your requests.

#1 no monitoring except for an initial 20 min strip, I could deal with just doing heart tones for most of your labor but would want to keep an option of doing more efm if something was concerning.

#2 no pit in 3rd stage I just wonder why? I mean pit in the 3rd stage is pretty benign and could be very important for decreasing your risk of nasty pp hemorrhage.

#3 the baby meds .. they also are pretty safe and go along way in helping babies, I guess I can understand the eye antibiotic... if you are sure you have never had any of the infections it is meant to protect the babies eyes from. but the vit K ? please explain why this would bother you.

#4 no IV fluids, as I said before as long as you are well hydrated a hep lock would be great, but labor tends to dehydrate you at a faster rate then you can take in P.O. a little IV fluid helps both mom and baby allot if its needed.

#5 only pushing when you feel the urge, I would love it if our doc's supported this and if yours did I wouldn't have a problem with it. What would worry me is if you started pushing against a thick anterior lip and swelled up I have terrible memories of a patient that did this and refused to stop who ended up losing her cervix.

#6 no vag checks and no coached pushing makes it really hard to get the doc in just in time to catch the baby and out in under an hour (which is what they expect of us)

As i said in the beginning I think your choice to home birth is a good one because in order for things to go the way you want them too you would have to have a good understanding with everyone involved in your labor and that is only possible in a home birth scenario. Please understand that I don't mean any of this in a bad way. I think home birth is great and would love to learn more about it. I just don't think you would be happy with a hospital birth and if I were your nurse I would feel really bad.

In fact I'm felling pretty rotten about a patient I had today. She came in with the hope of being as natural as possible and ended up with pit augmentation, IUPC, FSE, an epidural and a foley. she wasn't as passionate as you about natural birth but was very open minded. If I had had my way she would have had none of those things but the doc wanted pit and 1 thing lead to another.

Are you planning on being a dula for home birth or hospital?

I understand where you are coming from for the most part. With my first, episiotomies were more routine and they put me on pit because I wasn't laboring as fast as they wanted me to. I was very uninformed about the medical interventions (young and dumb, I was) and just accepted whatever they told me. Second pregnancy was a bit more researched and I had a birth plan that wasn't quite like yours, but there were a lot of people who thought I was a bit crazy. For example, in this town, it is very common for a lot of the labors to start out as inductions and it is very rare to see someone go past 40 weeks. I was very adament with my MD that I wanted NO intervention until I hit week 42, or my baby was in distress. So, I went 10 days past my due date. I figured, as long as baby was healthy in utero, I had an uncomplicated delivery with my daughter, why should I force my body to do something it may not be ready to do at week 38, 39, or even 40. During labor, I also had some demands as well.

I know that you are not pregnant now, and you want to have a home birth with your next one. If you plan on having a home birth, I would assume that you wouldn't go to the hospital unless medically indicated by your mid-wife or OB doc. And in that case, I think the intermittent EFM, at the very least would be a good idea. Also, I totally agree with your opinion about vag exams throughout labor. But how about the initial exam, and then when you feel like you need to push, an exam? For the very reason that DayRay mentioned in her post about the cervix.

I'm not going to remember all of the questions, but I'll attempt at answering what I can remember.

re: 3rd stage pitocin: I prefer the natural oxytocin my body has in ready supply to reduce my risk of pph. By nursing within minutes of birth, I create plenty. I also am extremely careful with my diet during pregnancy, which is a huge factor in hemorrhage risk. If I don't need it, I don't want it. (Ever hear about the old placenta under the tongue trick? Works just as well).

re: Vitamin K: A lot of this is based on my religious beliefs. What I mean by that is I don't believe God would make such a mistake as to create in all newborns a deficiency that would have such dangerous implications. I am willing to believe that this injection is beneficial and even necessary for high risk newborns, but not for all babies. I believe the impetus behind mandatory injection lies in the pharmaceutical companies who manufacture the synthetic vitamin.

re: PO hydration vs IV: This is where my husband comes in. I'm sure an IV is very beneficial to a woman with inadequate labor support, because it's hard to remember to drink while you're trying to deal with pain. My husband has my tea ready and brings the straw to my lips after almost every contraction, so I stay well hydrated.

re: lady partsl exams: I do request an exam when I think I'm feeling pushy. At my last birth, I did a few test pushes and called in the midwife, who found me to have an anterior lip and only 7 cm dilated. We waited, with me on hands and knees, and I was ready to give birth thirty minutes after that.

re: Why would a woman birth in a hospital if they didn't want all those things done to her? This is the most important thing I wish I could convey. I, personally, birth at home for that very reason. I don't want all those things done to me. I don't want the fight. I want the spiritual nature of birth honored, and I don't want strangers attending me. BUT, that does not mean this choice is right for all women. In fact, most women still birth in the hospital, even though some percentage of them don't want the routine interventions.

Someone mentioned that they are frustrated when a woman comes in and doesn't want their help until things go wrong. I'm here to say that for many women, that is the ONLY reason they're choosing hospital over home. They're there "just in case" but that doesn't mean they should submit to whatever arcane policy exists there when they have the right to refuse interventions. Why do they have to accept "help" in the form of routine interventions just because they walked through the doors? Why can't a woman come to the hospital and be left alone, and only utilize the staff in the event that their expertise is truly needed? I would think that would be less frustrating, not more.

re: Doula: I'm sure I will assist some homebirth clients, but I'm assuming I will work primarily in the hospital, since that is where doulas are most needed in my area. I will consider my role as an empowerer of women and not an advocate. I won't be there harassing the hospital staff, but I will help my clients educate themselves and ask questions when they need to. It's not my time yet, so for now, I do what I can empowering and educating women I find online.

Thanks again,

Sarah

Specializes in MS Home Health.

Sarah I hope your pregnancy will go well for you and your baby. I just know I would have died in childbirth with my 1st and 2nd had it not been for all the great nurses , Dr.s and monitoring they did for me in combination with meds to facilitiate my labor.

Hugs,

renerian

Originally posted by keeper

...re: Vitamin K: A lot of this is based on my religious beliefs. What I mean by that is I don't believe God would make such a mistake as to create in all newborns a deficiency that would have such dangerous implications. I am willing to believe that this injection is beneficial and even necessary for high risk newborns, but not for all babies. I believe the impetus behind mandatory injection lies in the pharmaceutical companies who manufacture the synthetic vitamin.

I am sorry but in my opinion you just became a difficult patient.

A parents decision to with hold blood transfusions is one thing but to not give a medication when there is statistical evidence to support its safe and necessary use is unconscionable.

The next question that comes to my mind is do you vaccinate?

I think the things that scare nurses about patients who don't want to have the interventions our policies require are 1: my hospital's policies are based in evidence and aren't out of date so they are there for the safety of my patients and 2: lawsuits. I am a big supporter of natural birth and letting the birth experience be controlled to a large extent by the mother's wishes, but the ones who want the least interventions seem to be the first to sue if things don't go well. For that reason I think every hospital should have waivers that a patient can sign to relax the nurses a little. That way everyone gets what they want.

Sorry, but honestly I am not sure why you would refuse such important interventions. Intermittent fetal heart check with a doppler is fine,but it is impossible to detect late decels by this method, which are a sign that the placenta is not providing the baby what it needs. Very dangerous sign! The vitamin K is so important for a newborn, along with the hepatitis vaccine. I can completely understand you thoughts on some of your requests, but we are really just looking out for what is best for you and yor baby. To each his own and as long as the risk is low, I think a birthing center is the place for your plan.

What would happen if you came into the hospital to deliver, we went along with you birth plan, but during your labor the baby was having late decels, not noticed, because of the fact we aren't permitted to provide continuous monitoring, and then you start to push when you feel the urge, but sionce we were not able to do a vag exam, the docotr is not there for the birth. The baby is norn and not breathing with a heart rate of 40. The nurses perform resuscitation, but it is too late. The what?? It is situations like this that put nurses and doctors in major lawsuits. You can tell me until you are blue in that face that you would not accuse anyone of anything because it was your decision, but until you are put in that situation, you cannot honestly tell me what you would do. The loss of a child brings along with it strong emotions and feelings about who did what wrong. I would fear caring for you in the hospital from a risk management point of view.

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