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.
Babynurse, several studies have shown that outcomes for low risk women do not improve when using continuous EFM as opposed to intermittent monitoring. The reccomendations from the college of ostetricians and gynecologists is that intermittent monitoring is the preffered method in low risk pregnancies.
I wouldn't consider you a difficult patient, but I would feel like it was part of my obligation to you to go over the risks/benefits and make sure you understood what you were doing (and it sounds like you do). I would be very uncomfortable if you came in having hard labor and weren't able to talk, or if I thought you were in such pain that you couldn't make decisions. Just because I want to personally know that you have the facts before I do/don't do something that could hurt you or your baby. Remember to be patient when your caregivers want to feel you out re knowledge level. Most will abide by your wishes, I think, so long as they are assured that you know the risks of what you are doing.
keeper - again, the majority of things you are outlining are very "doable", but I've got to say that the way you are expressing it, (though this may be the limitations of print, without vocal or facial cues) seems rather more aggressive than assertive. I almost get the impression that you feel staff is "lying in wait" in the hospital with the intention of subjecting you to all manner of unnecessary invasions. This may lead to staff considering you "difficult" even if that is not your intention. I really believe that setting up a meeting to discuss this with several of the nurses on the unit before you are in labor is the best way to avoid this. Also, this would allow the nurses to arrange that those who would be most comfortable with your preferences in birthing to arrange to be the ones to care for you.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Again, all of this points to one IMPORTANT INTERVENTION ON YOUR PART:
Initiating face-to-face discussion EARLY ON with your health care providers to avoid misunderstandings on anyone's part. Without this, the risk of miscommunication and resulting problems is almost a certainty.
Most nurses are willing to bend over backward to accomodate your wishes and our best hopes are for healthy mom and baby. Open communication on both sides will facilitate this more than anything else.
At least you're going to the hospital. My brother and his wife were talked into a home birth by some quack mid-wife. No prenatal testing or anything. It would have lived if they were in the hospital. End of story.
You can express your wishes all you want to the doctor, but that doesn't mean you will get what you want. I have seen patients come in with a plan for their birth, after reading info on the internet, and really, they don't have a clue. Yes, it would be nice if all births were lovely, happy, problem free events, but that is not the case. There are too many variables, and something can go wrong in a heartbeat. The hospital is not trying to make it more difficult, just trying to use all measures available to prevent complications and allow Mom and baby to be taken care of. Not everything is a conspiracy. (meaning the vitamin K injection)
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.
sarah
things do go wrong, and relying on a piece of placenta is a strange idea. you have never seen a woman keep on bleeding. chances are you won't, but it can happen very quickly.
as far as vitamin k is concerned, newborns do have deficiencies, not all babies are born perfect. you do have the right to refuse, but why want to take chances with the life of a child? you can refuse all of the baby's newborn care, but this is not your life. it's his or hers.
I don't work L/D but I work NICU and I've had a few experiences with parents that had birth plans. A typical scenario is that their baby has to come to us for whatever reason and then we get into a discussion about the erytho oint and vitamin K. We feel they need to know the risks of not having, particularly the vitamin K. A lot of times they're pretty irritable about being asked so often by the time the baby is born. I assume they've been through it with their OB and the nurses in L/D (perhaps from more that one shift) and then the nurses and Neo's in the NICU. They've lost the birth experience they want by having their baby in the NICU and now they've been lectured for the Nth time about the vitamin K and how their baby can die, etc etc. They're frequently labelled difficult by us because of this, but they're probably just getting sick of hearing about it over and over again.
My point is that parents that choose this should realize that they will probably be lectured about it and be expected to explain themselves several times. Just having a signed waiver doesn't deter us in the NICU from giving them "the talk" again.
I am not sure if I would "label" you as a difficult patient or not. I would however be a bit concerned with my name being in that chart in the event of a negative outcome. I do agree with quite a bit if your plan... no IV just hep lock, eating drinking, moving. I would however have an issue with the no monitoring thing. My question to that is WHY? I understand that you want the freedom to not be tied to the bed and be able to utilize positions to facilitate your labor. BUT... how would you live with yourself if something horrible happened to your baby and the staff was not able to inform your doctor of anything suspicious and the end result was a dead baby? I am not quite sure I understand the no monitoring for even 15 min per hour. Even a normal low risk pregnancy can come with problems. Labor puts a different stress on the placenta thatn anything that has occured during the pregnancy. YOU JUST NEVER KNOW! Wouldn't it be beneficial to at least get a little bit of a strip. You say you would allow interventions in the event of fetal distress but how would anyone know you or your baby needed help? Isn't a little inconvenience to you worth a healthy baby? As for the vag exams, I don't personally know of any nurse who does them as routine. For the most part we have all been in the patients situation but sometimes a vag exam is needed. Let me just give you a run down of how this may play out...Toting along just fine, progressing as hoped, no monitoring as you wished. Then your water breaks, GREAT!!! moving right along. No vag exam per your request, no monitoring per your request. Then maybe an hour or so later you feel the urge to push and whattya know cord comes out before the baby. Never had any suspicion of cord prolapse because when your water broke, efm was not placed to verify heart tones, never had sve to verify no prolapse. By the time it was detected your baby had been without oxygen for, oh maybe an hour. Who could survive that? And you know, funny thing, prolapse happens in normal low risk pregnancies. There isn't any warning, just happens. There is nothing in the prenatal period that can detect that is going to happen. How would you rationalize that to yourself? That my selfishness in not wanting to be inconvenienced with the monitors cost me the life of my baby? Yikes!!!Every pregancy and delivery is completely different. Just becasue one goes without complications does not gaurantee that all other deliveries will be uneventful. And pushing regardless of sve and patient with urge to push...How many of you L&D nurses have had a patient call out and say they needed to push and with an sve found they were only 6cm (or whatever). Depending on how low your baby is you may have the "uge to push" before your cervix is ready. If your are complete I totally agree with not pushing until the urge hits, but what if you have the urge to push and you aren't completely dilated?Arewe to allow you to push against a 4cm cervix and let it swell and increase your risk for cevical laceration?
I am a nurse that compltely agrees with patient advocacy and patient rights but when does that cross over to child endangerment. There are times when interventions are necessary but the people that are there to help you have a happy and safe outcome need to be aware of problems when and if they arise. I don't have very much faith in signing the waivers. How well will those stand up in court? I don't want my life and career ruined becasue you woldn't allow us to help you in keeping your baby safe. As I said I do agree with alot of what you wish, but when does it become unsafe for everyone involved?
just some points to ponder. If you are willing to accept all responsibiltiy and can live with the results then be my guest, but I don't think I could handle it if something that I chose resulted in the death of my child. Allwoing EFM does not negate your right to chose what path to follow in the labor and delivery process. But you can't make an informed decision if there is no information.
"You can express your wishes all you want to the doctor, but that doesn't mean you will get what you want. "
And some wonder why I seem aggressive? Do I not have a right of refusal in your hospital at all? This is the kind of attitude I was up against in my hospital births. This is precisely why I don't mind being labeled as a difficult patient if it means having my wishes respected.
"Things do go wrong, and relying on a piece of placenta is a strange idea. "
It may be strange to you, but I assure you, it is very effective. It is only used as a treatment in the event of an actual hemorrhage, as opposed to routine 3rd stage pitocin, which is used on all women indiscriminately. I just prefer treatment to prophylaxis.
"My point is that parents that choose this should realize that they will probably be lectured about it and be expected to explain themselves several times. "
I don't have a problem with this at all. Do what you feel you have to do in good conscience. It's not important to me whether or not you agree with my wishes, just that you respect them.
"I would feel like it was part of my obligation to you to go over the risks/benefits and make sure you understood what you were doing (and it sounds like you do)."
Again, this is something I have no problem with. In fact, I see it as a good thing. I have a very hard time with the lack of true informed consent I see in many hospitals around the country. Even though you would probably not change my mind, I would be glad to have a discussion on the risk/benefit ratio. If nothing else, it would show you I've already assessed that information.
"If your are complete I totally agree with not pushing until the urge hits, but what if you have the urge to push and you aren't completely dilated?"
I answered this question in a previous post. Please read it there.
"That my selfishness in not wanting to be inconvenienced with the monitors cost me the life of my baby?"
Do you consider all your mothers who have specific feelings about their own comfort and experience selfish? There are risks to epidurals and all pain relieving drugs during labor, and yet the only reason they are used is for the comfort of the mother. Is that mother selfish? I have no problem with intermittent monitoring with a dopplar, even fifteen minutes worth, if that makes the nurse feel better. I'm sure it's much more efficient, time wise, for you to come in and look at a piece of paper, but in order for the EFM's I have experienced to get a good reading, I had to be on my back. Funny you have no problem with the weight of my uterus resting on the vena cava and obstructing blood flow to the placenta. (Of course, the EFM would pick up the distress from that, wouldn't it.)
If your baby starts to show signs of distress will you allow ALL of the interventions that you decline in the first place? In other words if things go bad will you allow any and all interventions the nurses/doctors want or will you allow some and refuse others? If you will allow some and refuse others... what knowledge base will you draw on to decide? Certainly you've researched what is and what isn't necessary during a normal birth but do you know what of those interventions are essential and what aren't in the event of trouble? And if something goes wrong which interventions are necessary and which can still be safely declined depending on what it is that's going wrong?
Also, (speaking as a NICU nurse) if your baby has to go to the NICU will you still refuse the vitamin K/erythro/HepB or will you consider them? If you will still refuse do you feel you have the medical knowledge to refuse something when the birth process and postpartum period is something other than normal for your baby? If your baby has to go right to the NICU after birth will you consider pitocin since you won't be able to breastfeed immediately after delivery?
fergus51
6,620 Posts
Babynurse, several studies have shown that outcomes for low risk women do not improve when using continuous EFM as opposed to intermittent monitoring. The reccomendations from the college of ostetricians and gynecologists is that intermittent monitoring is the preffered method in low risk pregnancies.