INTRODUCTION
1. LET LABOR BEGIN ON IT'S OWN
2. WALK, MOVE, AND CHANGE POSITIONS
3. HAVE CONTINUOUS SUPPORT
4. AVOID UNNECESSARY INTERVENTIONS
5. GET UPRIGHT AND FOLLOW URGES TO PUSH
6. KEEP YOUR BABY WITH YOU
Thursday, March 18, 2010
Friday, March 12, 2010
Increase Womens Access to VBAC! Petition
Increase Womens Access to VBAC! Petition
I've signed this petition and urge all of you to do the same!
I've signed this petition and urge all of you to do the same!
Thursday, March 4, 2010
Informed Consent - The Myths Vs. Reality
When discussing maternity health care practices there is one phrase that will inevitably be mentioned and that is informed consent. The belief is that women should have informed consent before any procedure, intervention, or alternative action is taken by the provider before, during, or after labor and birth. This supposedly ensures that she is given the optimal chance at being involved in making choices regarding her health care, but does it really?
The Surgery Encyclopedia defines informed consent as: a legal document in all 50 states. It is an agreement for a proposed medical treatment or non-treatment, or for a proposed (emphasis mines) invasive procedure. It requires physicians to disclose the benefits, risks, and alternatives to the proposed treatment, non-treatment, or procedure. It is the method by which fully informed, rational persons may be involved in choices about their health care.
Let's examine the language and implications of that definition. On paper and at first glace, informed consent seems like the gold standard in allowing for participatory practice in maternity health care, but upon closer examination there are some limitations. Because informed consent begins with the caregiver proposing a certain course of action, it suggest that the caregiver has already decided that action is best. Yes, the practitioner may disclose information on not taking that particular action, or other alternatives, but is this enough to be considered participatory care? Let's look at an example of how informed consent may be given:
In that scenario many would argue that she was given informed consent and in the truest definition of the word, she was. The doctor proposed a course of action, told her the risks and benefits of that action and also discussed the option of not taking that action. He also presented another option (although the patient was already aware of the option and had already declined it) However, when we consider that scenario closely, it's then we can see the true limitations of informed consent. Did the doctor prescribe that particular course of action without bias? Since that action was the only alternative mentioned besides one the patient clearly did not want, I would be inclined to believe no, he did not. The bigger question is why weren't more alternative augmentations discussed? There are a host of different options that could have been presented but were not.
Having said all that, it has been clear to me for a long time that we need more than informed consent to really be participants in our maternity care. We need informed choices. As I learned from both my Doula studies and experiences, the act of informed choice is a process. It suggests that a dialogue is opened between the practitioner and patient. The communication is such that in certain situations the patient may face, multiple options are presented to the patient, with risks and benefits of each, in addition to the option (if possible) of doing nothing. The patient can then carefully weigh the pros and cons of all viable options, without pressure or bias from the practitioner, and then can give her informed consent. Informed choice invites the patient to truly become a participant in her care, and should always be the first step before obtaining informed consent. In this scenario the caregiver has engaged the patient and in doing so builds a positive atmosphere in the birthing room. No longer is the caregiver inviting the patient to "sign off" on a procedure or course of action the he deems necessary, but is "engaging in a dialogue to help the client take responsibility for her own choices."
In closing this post, I want to add that it is important for expectant mothers to know that there can be situations that are true emergencies. In these situations it goes without saying that discussions will have to be limited, if there is time for any at all. This is another reason why informed choices are so valuable, because the act of discussing choices and options should happen not just during labor, but throughout pregnancy at prenatal visits. The open dialogue and subsequent trust the practitioner fosters as result is invaluable in those instants of true emergencies. Not only does the doctor get to understand his patients wishes more deeply, but the patient in turn is able to trust the doctors expertise and opinions if an emergency should arise.
The Surgery Encyclopedia defines informed consent as: a legal document in all 50 states. It is an agreement for a proposed medical treatment or non-treatment, or for a proposed (emphasis mines) invasive procedure. It requires physicians to disclose the benefits, risks, and alternatives to the proposed treatment, non-treatment, or procedure. It is the method by which fully informed, rational persons may be involved in choices about their health care.
Let's examine the language and implications of that definition. On paper and at first glace, informed consent seems like the gold standard in allowing for participatory practice in maternity health care, but upon closer examination there are some limitations. Because informed consent begins with the caregiver proposing a certain course of action, it suggest that the caregiver has already decided that action is best. Yes, the practitioner may disclose information on not taking that particular action, or other alternatives, but is this enough to be considered participatory care? Let's look at an example of how informed consent may be given:
A first time mother arrives at the hospital, membranes still intact, having regular contractions at about 6-7minutes apart. She has already labored at home for more than 8 hours. During her cervical check, it is discovered that she is only about 3cm dilated. Her contractions are manageable to her, but she can't help but express disappointment that she isn't further along. She doesn't have a written birth plan, but wants to labor without pitocin or other forms of drug augmentation because of fear of what it might do to her labor. After an hour of laboring in bed on monitors, her labor begins to slow. Her contractions are spacing and getting weaker in strength. Although her baby is fine, and she is doing well, her doctor suggests (trying to honor her wishes to avoid pitocin) that her membranes are artificially ruptured. He goes on to tell her that because they rupture her membranes, they may have to monitor the baby more closely as labor is better tolerated by baby with membranes intact, and that there is a slight risk of infection and fever if she labors too long with her membranes ruptured. He tells her the benefit is that it may put her in a better labor pattern and make the contractions longer, closer together, and generally more efficient. He also tells her that her that she could wait a few hours and see what happens considering the baby is looking good, but that in his experience, once a labor stalls, it usually requires some action to get labor going again. He reminds her that, although he knows she doesn't want pitocin, it is still a viable option that usually yields the fastest results. After hearing all of this, the mother decides to have her water broken, and in 7 more hours goes on to delivery her baby vaginally. She did, however, require an epidural (which she was also trying to avoid), not only because of the intensity of the contractions after her water was broken, but because she wasn't allowed to labor outside of the bed. The lack of freedom of movement increased her perception of pain.
In that scenario many would argue that she was given informed consent and in the truest definition of the word, she was. The doctor proposed a course of action, told her the risks and benefits of that action and also discussed the option of not taking that action. He also presented another option (although the patient was already aware of the option and had already declined it) However, when we consider that scenario closely, it's then we can see the true limitations of informed consent. Did the doctor prescribe that particular course of action without bias? Since that action was the only alternative mentioned besides one the patient clearly did not want, I would be inclined to believe no, he did not. The bigger question is why weren't more alternative augmentations discussed? There are a host of different options that could have been presented but were not.
Having said all that, it has been clear to me for a long time that we need more than informed consent to really be participants in our maternity care. We need informed choices. As I learned from both my Doula studies and experiences, the act of informed choice is a process. It suggests that a dialogue is opened between the practitioner and patient. The communication is such that in certain situations the patient may face, multiple options are presented to the patient, with risks and benefits of each, in addition to the option (if possible) of doing nothing. The patient can then carefully weigh the pros and cons of all viable options, without pressure or bias from the practitioner, and then can give her informed consent. Informed choice invites the patient to truly become a participant in her care, and should always be the first step before obtaining informed consent. In this scenario the caregiver has engaged the patient and in doing so builds a positive atmosphere in the birthing room. No longer is the caregiver inviting the patient to "sign off" on a procedure or course of action the he deems necessary, but is "engaging in a dialogue to help the client take responsibility for her own choices."
In closing this post, I want to add that it is important for expectant mothers to know that there can be situations that are true emergencies. In these situations it goes without saying that discussions will have to be limited, if there is time for any at all. This is another reason why informed choices are so valuable, because the act of discussing choices and options should happen not just during labor, but throughout pregnancy at prenatal visits. The open dialogue and subsequent trust the practitioner fosters as result is invaluable in those instants of true emergencies. Not only does the doctor get to understand his patients wishes more deeply, but the patient in turn is able to trust the doctors expertise and opinions if an emergency should arise.
Monday, February 15, 2010
If you are happy with your choices, why does mine bother you so much?
I'm not usually one to go on a rant. Not that people who rant are doing this, but when I do I always feel like I am jumping to conclusions. Perhaps I over analyze things for fear of making assumptions. Having said that, I feel a rant brewing. I believe it's been cooking up from weeks of reading articles and then foolishly going through the dreaded comments section. Seriously, if you for some reason want to change positive energy to negative energy, read the comments section of any controversial story and that outta do trick!
My rant is about peoples choices. Yes, I write about choice a lot, because I, like the great Morpheus of the Matrix, believe everything begins with choice. Let's examine the word for a minute. Choice in it's most stripped down form, implies ownership, yet I don't think people always own their choices. They may think they do, but their actions, emotions, and words say otherwise. I believe when people don't own, or take responsibility for their choices, it's usually because they are not happy with them. When you are happy with your choices, you don't feel the need to defend them or explain them. Or my favorite, get defensive and hostile when a person makes a choice opposite yours.
Example #1. I chose a natural birth. I blog about my experience and my satisfaction with my choices. You, having chose a medicated birth, read my blog and immediately become defensive. You launch into explaining why you had the birth you did. You also accuse me of trying to make people who don't birth "naturally" feel bad.
So, not only are you seemingly unhappy with your choices, you are also not owning your feelings, by blaming me for how you feel about your choices.
Example #2. A story is written about the high induction rate, and how many of the inductions done are not medically indicated. The article talks about the risks of inductions, one being the cascade of interventions that can sometimes lead to unnecessary cesarean sections. Again a woman who chose an induction reads the article and feels attacked. She explains her baby was suspected to be too big at 39 weeks. She needed an induction. Later as the induction failed she found out her baby was in danger and she needed an emergency c-section (that took 2 hours to happen from the moment the doctor say c-section time, to the moment she was on the table). The baby is delivered and low and behold her baby was 8lbs and she is only 5'4! She is pissed that anyone would assume her induction and subsequent cesarean was unnecessary!
In that scenario, one might argue that the women really didn't have a choice, because she was not given true informed consent and while I can agree with that, I don't agree that she sees it that way. She is angry that her decision to have an induction is questioned, and so again I have to wonder how secure she is in her decision. Perhaps maybe she feels she didn't have all the facts. Perhaps she secretly wonders how necessary her cesarean section was, but if she allows herself to question the events, she questions her judgment and role in the events that took place. That is an admittedly hard thing to do.
There are other examples I could give, but I'll stop with those two. The bottom line is that when a person is happy and secure in the choices they've made, another person words or actions can not make them feel otherwise. If you've felt defensive, angry, or guilty about choices you've made, you have to explore why, instead of blaming others. Own your feelings and take ownership of your choices.
My rant is about peoples choices. Yes, I write about choice a lot, because I, like the great Morpheus of the Matrix, believe everything begins with choice. Let's examine the word for a minute. Choice in it's most stripped down form, implies ownership, yet I don't think people always own their choices. They may think they do, but their actions, emotions, and words say otherwise. I believe when people don't own, or take responsibility for their choices, it's usually because they are not happy with them. When you are happy with your choices, you don't feel the need to defend them or explain them. Or my favorite, get defensive and hostile when a person makes a choice opposite yours.
Example #1. I chose a natural birth. I blog about my experience and my satisfaction with my choices. You, having chose a medicated birth, read my blog and immediately become defensive. You launch into explaining why you had the birth you did. You also accuse me of trying to make people who don't birth "naturally" feel bad.
So, not only are you seemingly unhappy with your choices, you are also not owning your feelings, by blaming me for how you feel about your choices.
Example #2. A story is written about the high induction rate, and how many of the inductions done are not medically indicated. The article talks about the risks of inductions, one being the cascade of interventions that can sometimes lead to unnecessary cesarean sections. Again a woman who chose an induction reads the article and feels attacked. She explains her baby was suspected to be too big at 39 weeks. She needed an induction. Later as the induction failed she found out her baby was in danger and she needed an emergency c-section (that took 2 hours to happen from the moment the doctor say c-section time, to the moment she was on the table). The baby is delivered and low and behold her baby was 8lbs and she is only 5'4! She is pissed that anyone would assume her induction and subsequent cesarean was unnecessary!
In that scenario, one might argue that the women really didn't have a choice, because she was not given true informed consent and while I can agree with that, I don't agree that she sees it that way. She is angry that her decision to have an induction is questioned, and so again I have to wonder how secure she is in her decision. Perhaps maybe she feels she didn't have all the facts. Perhaps she secretly wonders how necessary her cesarean section was, but if she allows herself to question the events, she questions her judgment and role in the events that took place. That is an admittedly hard thing to do.
There are other examples I could give, but I'll stop with those two. The bottom line is that when a person is happy and secure in the choices they've made, another person words or actions can not make them feel otherwise. If you've felt defensive, angry, or guilty about choices you've made, you have to explore why, instead of blaming others. Own your feelings and take ownership of your choices.
Saturday, February 13, 2010
Sunday, January 10, 2010
Are we advocating for Choices or The Choices we would make?
You are sitting at your favorite in-door play area with your little one, talking to another mother who frequents the spot. She just had a baby and you are super excited to hear about the birth. She begins to tell you that at her 38 week check-up her OB said the baby was measuring big (oh boy, here we go), and so an induction was scheduled. Of course she remarks on how the doctor said it was safe and she was full term, so she agreed. By this time you've kept that smile on your face, but are feeling you could easily continue this story for her. She goes on.
At 6am (why are those things scheduled so damn early in the morning), she arrives at the hospital, does the paperwork, changes into the gown, blood work, yada, yada, yada the doctor comes in at 9am. Wait, why did she have to come in a 6am? Oh well, you keep nodding. The doctor decides because she a multip (she tells you admitting she didn't know what the hell a multip meant, but didn't ask either) and already dilated to 2cm that he would break the water and start a low dose pitocin drip. You nod at her, but your heart drops inside.
So she talks about how as soon as that pitocin was put in she is deep pain. She kept wanting to get up, but the nurse kept telling her no. She says the nurse said the best thing to do was to get the epidural, but she would have to wait until she was 4-5cm. Of course, she thought that was pure torture, but she made it. She got the epidural and everything was copasetic. She tells you how she was playing cards with her husband, chatting on the phone, and it was hard to believe she was actually in labor, because with her first baby, she didn't get the epidural until she was 8cm. Wait, why did she get the epidural at 8cm? Never mind that's a whole different story.
So, by now it's 7pm and she has been stuck at 7cm. You nod, ready for what you've known was coming. Yes, you guessed it. Decels! The doctor tells her that he will give it one more hour. Wow, a whole hour really? And by now your friend is getting really scared. She says she didn't know what to do, but understood that the doctor knew what he talking about and decided to try and relax and pray.
So the prayers worked because in an hour, she became fully dilated. You perk up again, happy to hear that she wasn't sectioned! But wait, baby is hasn't moved down the birth canal. Oh, yeah, she's been laying her back this whole time. So after 2+ hours of pushing it's c-section time because after all, that is a big baby in there.
So you ask. How big was she? When the mother tells you 7lbs 8oz you force a smile and say she is so precious, because, what else can you say?
So you ask your friend how she feels and she says good. She is just happy the baby is healthy, and nothing bad went wrong. She completely understands that those things happen, and that's why she chose to birth in the hospital with a doctor in the first place.
When you re-tell her story to your group of natural birthing advocates, the first thing you say is, How do I tell her that her c-section was unnecessary? And therein lies the conundrum. You don't, because quite frankly, did she ask you? Telling her that is tantamount to telling her that her choices were wrong. She doesn't feel that way and it certainly isn't anyone's place to try and convince her otherwise.
Almost everyday I read something like this from one of my colleagues and associates and I am frustrated on two levels. I am frustrated for the women who got put through a system that doesn't always have the best of interest of her or her child in mind; and I am also frustrated by the advocates that seem to forget that it's not about changing a person's mind. It's about educating women, giving them all the facts so that they can make the best choice for them and on a bigger level it's about bringing change to that system.
I would ask myself if I were the woman listening to the mother's birth story; Did I offer up information, advice, resources to this woman while she was pregnant? Did I talk to her then and really listen to her? If you did, in the end, that's all you can do. It's her choice. If a woman makes a choice to be induced, knowing the dangers of induction, it's still her choice. Just as it the woman who chooses not to be induced, or to have a home birth or an unassisted birth. Are we really advocating for choices, or just the choices we would make?
At 6am (why are those things scheduled so damn early in the morning), she arrives at the hospital, does the paperwork, changes into the gown, blood work, yada, yada, yada the doctor comes in at 9am. Wait, why did she have to come in a 6am? Oh well, you keep nodding. The doctor decides because she a multip (she tells you admitting she didn't know what the hell a multip meant, but didn't ask either) and already dilated to 2cm that he would break the water and start a low dose pitocin drip. You nod at her, but your heart drops inside.
So she talks about how as soon as that pitocin was put in she is deep pain. She kept wanting to get up, but the nurse kept telling her no. She says the nurse said the best thing to do was to get the epidural, but she would have to wait until she was 4-5cm. Of course, she thought that was pure torture, but she made it. She got the epidural and everything was copasetic. She tells you how she was playing cards with her husband, chatting on the phone, and it was hard to believe she was actually in labor, because with her first baby, she didn't get the epidural until she was 8cm. Wait, why did she get the epidural at 8cm? Never mind that's a whole different story.
So, by now it's 7pm and she has been stuck at 7cm. You nod, ready for what you've known was coming. Yes, you guessed it. Decels! The doctor tells her that he will give it one more hour. Wow, a whole hour really? And by now your friend is getting really scared. She says she didn't know what to do, but understood that the doctor knew what he talking about and decided to try and relax and pray.
So the prayers worked because in an hour, she became fully dilated. You perk up again, happy to hear that she wasn't sectioned! But wait, baby is hasn't moved down the birth canal. Oh, yeah, she's been laying her back this whole time. So after 2+ hours of pushing it's c-section time because after all, that is a big baby in there.
So you ask. How big was she? When the mother tells you 7lbs 8oz you force a smile and say she is so precious, because, what else can you say?
So you ask your friend how she feels and she says good. She is just happy the baby is healthy, and nothing bad went wrong. She completely understands that those things happen, and that's why she chose to birth in the hospital with a doctor in the first place.
When you re-tell her story to your group of natural birthing advocates, the first thing you say is, How do I tell her that her c-section was unnecessary? And therein lies the conundrum. You don't, because quite frankly, did she ask you? Telling her that is tantamount to telling her that her choices were wrong. She doesn't feel that way and it certainly isn't anyone's place to try and convince her otherwise.
Almost everyday I read something like this from one of my colleagues and associates and I am frustrated on two levels. I am frustrated for the women who got put through a system that doesn't always have the best of interest of her or her child in mind; and I am also frustrated by the advocates that seem to forget that it's not about changing a person's mind. It's about educating women, giving them all the facts so that they can make the best choice for them and on a bigger level it's about bringing change to that system.
I would ask myself if I were the woman listening to the mother's birth story; Did I offer up information, advice, resources to this woman while she was pregnant? Did I talk to her then and really listen to her? If you did, in the end, that's all you can do. It's her choice. If a woman makes a choice to be induced, knowing the dangers of induction, it's still her choice. Just as it the woman who chooses not to be induced, or to have a home birth or an unassisted birth. Are we really advocating for choices, or just the choices we would make?
Friday, January 1, 2010
Cesarean Scar Care in the Post-Partum Period: Hosted By ICAN
ICAN (International Cesarean Awareness Network) is hosting a Webinar at the end of this month designed for new moms and healthcare professionals alike who are looking to understand and implement some real-world techniques to get relief from pain, itching, burning, and tingling. It is also to learn how to restore the abdominal muscles and posture so that you feel like yourself again.
If you are a woman who is going to have a c-section or had one in the past, you can benefit greatly from this webinar. Please click the link here http://ican-online.org/webinars/cesarean-scar-care for more information.
If you are a woman who is going to have a c-section or had one in the past, you can benefit greatly from this webinar. Please click the link here http://ican-online.org/webinars/cesarean-scar-care for more information.
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