Archive for the ‘Informed Consent/Refusal’ Category

Do’s and Don’ts in Labor & Delivery (a.k.a. Getting What You Want, Kindly)

Monday, April 20th, 2015
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Birth plans. Epidurals. Natural Childbirth. Doulas. Induction. Cesareans. And more…

The list of decisions about birth goes on and on…

More women are becoming dissatisfied with the status quo in American maternity care, and are asking for something outside the norm for the hospital where they plan give birth. Naturally, this might make for some conflict between a birthing mother and her care provider and nursing staff.

Conflict.

There. I said it. Right out loud.

There might be conflict in the labor and delivery room when a mother is giving birth. I am not writing this post to tell anyone how to avoid conflict, but how to manage it in a healthy way, so that the birth experience is not characterized by the conflicts that arise, but by the solutions everyone involved is able to come to.

Here are some do’s and don’ts that may help you in the labor and delivery room to self-advocate effectively, while creating a human connection with the nurses and provider caring for you and your baby.

DON’T: Expect care providers or nurses to offer much in the way of comfort during labor.
It is not the responsibility of a care provider or nurse to make a birthing mother comfortable. Their first priority, and indeed, their entire job, is the safety of mother and baby. Period. Your comfort is a distant second to safety, and that’s exactly the way it should be.

DO: Hire a doula to offer you comfort and support.
Your comfort is the entire responsibility of your doula. Period. That is all that she is there for. Emotional, physical, and informational comfort and support are her expertise. You will not be disappointed if you lean on a doula for this need.

DON’T: Make demands.
This only causes a heightening of conflict. If you want something different than protocol, shaking your fist and demanding it is not the right tack. You might get your way, but you may not end up getting the best care if you treat the nurses as if they were there to grant your every wish.

DO: Ask for exceptions.
Think about it. How would you feel if a stranger came to your house, and began to dictate to you how to load your dishwasher, feed your kids, or fold your towels? You would be offended. This is what we do when we demand our way in labor. When you want something outside protocols, try this: “I understand that this is your normal protocol, but I need you to make an exception for me this time. Thank you.” This invites conversation and cooperation, and is less likely to put a nurse (who is technically your advocate) on the defensive.

DON’T: Be rigid.
Refusing to budge on the smallest things is unfair, especially when you are asking for things outside the box. Remember, you are a rare breed to these nurses. Asking them to step outside their norm is a big deal. Respect that.

DO: Be flexible.
Compromise is the name of the game. For example, here in Colorado Springs, a Hep lock buys you pretty much anything you want in most of the hospitals. It helps them to see that you are reasonable, and that you understand why they do what they do. It makes them far more open to your requests and out-of-the-box needs.

DON’T: Wait until you are in labor to make your birth plan known.
It is completely unreasonable to spring a birth plan on unsuspecting staff and providers. You can’t count on appointment conversations to be remembered, simply because of the sheer volume of patients a hospital-based provider might see in any given month. Not to mention the fact that you are likely to have a care provider you’ve never met catching your baby!

DO: Discuss everything on your birth plan prentally.
Write your birth plan early, in second trimester, and tackle one issue at a time in those 7-10 minute appointments. Discuss the benefits, risks, and alternatives ahead of time, and really make sure you and your provider are on the same page. If they are willing, have them sign it–this doesn’t make it a legal document, but it proves to the staff and on-call doc that your care provider is on board with all your requests.

In short, it pays to be kind. Always be kind. You never know what kind of day your nurse or care provider has had. You have no idea what is going on in the room next to you. I am not making excuses for bad or disrespectful or hurried care. I want to remind you that everyone in scrubs is a human being, just like you. There is rarely a reason to walk into a labor and delivery ward with guns blazing. Even if you had no other choice in your care. The ones providing it are just as human as you are, and if you can leave them feeling respected and understood, you are helping to pave the way for the next woman who wants out-of-the-box care.

It may be your birth, but it has ripple effects. Whether it’s for the positive or negative is, at least in part, up to you.

How do you handle differences of opinion in your care? What are the most diplomatic ways you have used to self-advocate without a situation erupting into WWIII?

Grace & Peace,
Tiffany

A Message About Preeclampsia to Every Mother

Wednesday, June 4th, 2014

If your care provider is seeing a slight increase in your BP, a bit of protein in your urine, and asks you questions about headaches, swelling in your hands and face, pain under your ribs on the right, and if you’ve been seeing spots, they may tell you that you are turning preeclamptic. The Preeclampsia Foundation website can help clarify a lot of what they are telling you, and give you some tools to partner with your care provider in making sure of your diagnosis. Before you can proceed, having a good understanding of what you are facing is important for you and your baby’s health. A preeclampsia diagnosis is nothing to sneeze at, and therefore, it behooves you to learn what you can in order to participate fully in your care, and to make decisions based on information and instincts, rather than fear.

However, it is important to note that, if you do have preeclampsia, you are in a situation where the benefits of certain interventions (such as induction or occasionally cesarean section) very likely outweigh the risks of waiting it out. Preeclampsia doesn’t play fair. It is imperative that you speak clearly with your provider, and make sure you understand why they are suggesting certain procedures. Even if they are necessary, they can be hard to take in if you were planning an unmedicated vaginal birth. Knowing really is half the battle in this case. Do not be afraid to learn about preeclampsia, learn about the way your care provider treats it, and walk forward in confident awareness of the power you still have to choose rightly for you and your baby.

Some things to consider if your blood pressure slightly elevated during only one prenatal visit, and in the absence of other symptoms:

  • What is your stress level like?
  • Have you been sick lately?
  • Are you dehydrated?

Some questions to ask if you have more indicators and/or symptoms:

  • “Am I being diagnosed with preeclampsia, or are these numbers borderline?”
  • “Could this be pregnancy-induced hypertension? If so, how do you normally treat it? Can it lead to preeclampsia?”
  • “What other symptoms might come to light if it is preeclampsia?”
  • “Do I have the option of monitoring BP at home, and being checked every couple of days, or does this need to be taken care of now?”
  • “Is the protein in my urine shown via a reagent strip, and if so, can we double-check it with a 24 hour catch?”
  • “What are my options for induction if it becomes necessary? What are the benefits/risks/alternatives of each method? Which do you prefer, and why?”
  • “How soon do you typically decide to move on to a cesarean section if the induction does not work?”

Preeclampsia is not the end of the world, though it is serious. It is just one of several curve balls that get thrown at some women. It is not something that we currently know how to prevent with any degree of scientific certainty. We have a lot of ideas of what seems to help, but nothing we can hang our hats on just yet. One thing that I think is so important to understand is that we can do everything “right,” have a textbook healthy pregnancy, and still end up with preeclampsia or other problems. We are never guaranteed a “good” outcome when it comes to anything in life, and we should not expect our births to be any different.

What matters most is to do the best we can with what we have, and to be flexible when we are handed something unpleasant, difficult, or even downright terrifying. We face our fears and challenges head-on, and make the best decisions we can within our circumstances. We do not lose our power just because of a medical diagnosis. We just lose a few options we otherwise would have had. Never be afraid to ask your care provider, “Why?” The more you understand, the less scary it will be for you, and the better you will be able to process your birth after the fact.

Preeclampsia or no, your birth is still your birth. You are already a good mother. You can do this.

What do you know about preeclampsia? Where did you get your information? Have you had preeclampsia before? What was your experience with it? What did you learn from it? What advice would you give to someone facing a similar situation? Share your story in the comments…

Grace & Peace,
Tiffany

 

7 Symptoms Every Pregnant Woman Should Know

Monday, May 19th, 2014

Pregnancy is weird. There is no denying that. It often comes with all kinds of odd symptoms as the hormones of pregnancy do not limit their effect to the uterus and growing baby. Everything from morning sickness to hemorrhoids to indigestion can be a normal part of pregnancy. These things are not often a cause for concern, but sometimes, these symptoms wander outside the range of normal, and it’s important to understand what that looks like.

There is a reason your care provider has you pee in a cup, takes your blood pressure, and asks about headaches, vision changes, and other symptoms. It’s best not to stay in the dark about why.

I don’t share this information to scare you, or to make you paranoid, but to bring a sense of awareness. When in doubt, it never hurts to call your provider. Peace of mind and good health are more important than feeling a little foolish. Take a minute to watch this video, and just tuck it away in an easily accessible corner of your mind.

Grace & Peace,
Tiffany

What’s the Deal With Cesareans?

Thursday, October 10th, 2013

Lamaze_CesaraenInfographic_FINAL

What You Need to Know About Birth Plans

Friday, September 27th, 2013

As a doula, I require all of my clients to put together a birth plan, discuss it with their care provider, and to provide me a hard copy. I make very few exceptions to this requirement. I believe firmly that a birth plan is a critical piece of the puzzle in good perinatal care.

As much as we want to believe that our prenatal care is individualized, it often is not. Even home birth midwives can get into a “this is how I always do it” habit, though that is far less likely. Still – I have learned to never take anything for granted when it comes to care providers.

I spend a good amount of time with each client in helping them form their own unique birth plan, and provide them with role-playing opportunities that teach them how to have open, honest, and clinical discussions with their provider about their individual needs. If I am hired late into the third trimester, that is almost all I end up doing prenatally – birth plan work.

It’s that important.

That said, I don’t particularly care for the term “Birth Plan,” and I use it only because that’s the common vernacular. I think the word “Plan” conjures up images of precise blueprints and/or legally binding documents. A birth plan is neither of those things, and the sooner we understand that, the better.

Instead, I believe that birth plans are tools designed to help you, your care provider, and any staff you encounter to communicate effectively about your individual needs and expectations regarding your care.

It provides a basic framework that helps your care provider and staff to better care for you, but it does not legally bind them to your every whim and wish.

Instead, a birth plan gives you and your care provider an opportunity to pursue individualized care together, and to be on the same page before you go into labor. It has the potential to build rapport, trust, and respect between you and your provider–a critical factor in enjoying a positive, healthy birth experience, no matter what the circumstances end up being.

For this reason, I really prefer the term “Birth Preferences,” “Birth Goals,” or even “Birth Desires.” Those make a lot more sense to me. When a birth plan is viewed this way, it is often much easier to mentally and emotionally process anything that derails those plans.

Birth is still unpredictable, and there are no guarantees, no matter how safe we have made it. The reality is that birth is like any major event we plan: There will always be at least one thing that does not go the way we expect it to, for good or ill.

Mommas get sick. Babies get sick. Babies get into funky positions. Mommas get exhausted. Heart rates get wonky. Side effects of drugs happen. Things stretch on longer than we thought, or go far faster than we anticipated.

Stuff happens.

Overall, birth is a safe and healthy process, but it has a lot of variables within a very wide range of Normal. Accepting that fact, and writing a birth plan with flexibility in mind is key to processing those funky things that happen during our births.

I find that the most flexibly written birth plans get the most respect from staff. They see clearly that my client has done her research, and has realistic expectations. Frankly, I find that my clients are more likely to get exactly what they want when their language is open and flexible.

I also find that when things get weird in a birth, staff and providers tend to bend over backwards to keep the spirit of the plan intact. They seem to view themselves as being on my client’s side, and try very hard to make it work within the parameters this particular labor has laid out for them.

My clients come out of these births processing all of it in a very healthy way. They understand that they don’t have to like what happened, but if they felt respected, understood, and as though their choices mattered, they are often okay in the long run. They understand that it’s okay not to be okay for awhile. They grieve the stuff they didn’t like, but are grateful for the support and good care they received within the circumstances their birth chose for them.

Care they might not have received had they not communicated clearly what they hoped for, ahead of time, via their birth plan.

So, when writing your birth plan, be careful about the language you use. Really examine how it comes across, and how you view your relationship with your care provider. Some basic tips:

  • Open with a sentence like: “We understand that circumstances may arise that preclude the following desires, but we expect to be fully informed before consenting to any procedure that may be proposed, and we appreciate your help in achieving a healthy and pleasant birth.” This lets them know you understand that birth has a lot of variables, and that you are willing to work with the staff.
  • Have a short introductory sentence or two explaining your overall desires. (Natural birth? Well-timed epidural?) The staff will automatically know what requests will go along with that, and you can eliminate a lot of specifics. For example: If you know you want an unmedicated birth, and state that fact right away, you won’t have to tell them you’ll want to move around, have dim lighting, etc…
  • Keep it simple. It shouldn’t be more than one page long.
  • Use bullet points and clinical language.
  • Tailor it to your provider’s practices, as well as the protocols at your place of birth. If you know they do rooming-in, you don’t need to request it.
  • Do your research. Take an independent childbirth class. Hire a doula.
  • Take your first draft to your provider and ask specific questions. “Under what circumstances might you do an episiotomy?” This helps you know if something needs to be added or taken off the plan.
  • Have a cesarean plan. Look up “Family-Centered Cesarean,” and choose your top 3-5 items you think might be important, and add those.

Be decisive and clear in your desires, but remember to stay open as well. Choose carefully your hills to die on, and let everything else go if it becomes necessary. Ask questions. Even if all you can think is to keep asking “Why?” That one word can gain you a lot more information when a decision becomes critical. Open your eyes, and walk forward confident in your desires, your ability to birth, and your ability to make good decisions for you and your baby.

You are already a good mother. Go for it.

I could write mountains of information on this subject, but this post would get too long. Did you write a birth plan? Why or why not? Do you feel your desires were respected? Do you feel it created a sense of cooperation with the staff who cared for you? Why or why not?

Grace & Peace,
Tiffany

Book Review: “The Vaccine Book” by Dr. Robert W. Sears

Saturday, May 19th, 2012

Image from goodreads.com

First of all: You have to know something about this book. It is not pro-vaccine. It is not anti-vaccine. It is pro-informed-consent for parents. It’s about information, not influence. Okay. Keep reading.

I thought this book was the most informative look at vaccines I have ever seen. So much “information” is so heavily biased, and contaminated with emotional “dead-baby” appeals, that I have been more confused than ever on what might be right for my kids. This book is filled with information straight from product inserts, and has a Resources section in the back for all those who want to read studies for themselves. Everything is documented, and when Dr. Sears is sharing his opinion – you know that’s exactly what he’s doing, because he labels it.

It is so refreshing to read something like this about a controversial topic!

This book helped me decide what I want to do for my kids, without ever telling me what to do. I feel as though it is an excellent tool that all parents should read before their first child is born. This is a book I am going to buy for my lending library as a doula and childbirth educator. Stat.

What’s the best book related to the childbearing year you have read? Do share!
Grace & Peace,
Tiffany

Some Say I Am Brave

Tuesday, May 8th, 2012

Image from http://www.vickidonlan.com

Some say I am brave for choosing homebirth. To me, that’s like saying I’m brave for having a big wedding. No matter how involved the planning, we all know the real work of marriage starts when the wedding is over.

So it is with birth. Our childhood, our growing up, and our pregnancy is the training ground. Birth is the opening ceremony. Motherhood is the marathon.

Some say I am brave for choosing homebirth. Others would counter that choosing a hospital birth is brave.

I say choosing to become a mother is brave, no matter where you choose to bring your child into the world. I say learning to make fully informed decisions — guided by a beautiful hybrid of evidence-based information and your intuition — is brave.

Doing this often means going against the flow of society in general, and the tide of modern obstetrics in specific.

It means navigating endless resources, asking questions, and taking time to figure out answers. It means identifying, confronting, and processing fears, anxieties, and stressors that hinder you from being able to fully trust your body and your chosen care provider. It means letting go of a process we have very little control over, when all is said and done, and forming realistic expectations about your birth based on your unique emotional health, health history, and risk factors.

It means being able to tell your well-meaning loved ones that you appreciate their input, but that you are choosing a different way than they did. It sometimes means being willing to give up your ideal for reality — whether that entails a homebirth transfer, an unplanned cesarean, or an accidental homebirth.

The location of your birth doesn’t matter nearly as much as how you got there.

Navigating the road on this journey isn’t as simple as using GPS systems to decide where to turn. It’s less like a road trip, and more like a sea voyage. You may have all the tools in the world in your boat, but unless you use them, the horizon looks exactly the same no matter which direction you look. Sure, you can guess which direction is the right way to go, but you can’t really know unless you have a destination in mind, and you’re able to use the tools around you.

It’s up to you to pick up those tools and make use of them. No one else is really in that boat with you.

It’s up to you to be brave.

Where do you want to go?

Do your homework. Take nothing for granted. Never say never. Then, when you know where you want to be, pick up the tools you have and get yourself there. No one else can (or will) do this for you.

Some say I am brave for choosing homebirth.

What really made me brave was my willingness to open my mind and look beyond the status quo at all the options available to me. That was the hard part. What continues to make me brave is looking four little ones in the face each morning, and loving them in spite of the challenges that mothering them presents.

Some say I am brave. I say that all mothers are brave; some just have not figured it out yet.

When did you realize your bravery as a mother? In what moments have you been brave as a mother?

Pick up good books. Take an evidence-based childbirth class. Know where evidence-based information resides on the internet. (It’s not typically at BabyCenter, just FYI.) Ask questions of your care provider every appointment. Hire a doula. Look outside your box. Interview providers you might not have considered. Confront your anxieties and fears about birth – with professional help if you think you need it.

Grace & Peace,
Tiffany

 

Induction is a Grey Area: How to use medical procedures to your benefit.

Thursday, February 23rd, 2012

Image from PregnancyBest.com

If you are facing an induction because you are approaching the 40-week mark, and your care provider does not want you to go past your EDD, you have more than one option available to you. This is not an all-or-nothing proposition. The burden of proof for induction, no matter the reason, lies with your care provider. It is their prerogative to make sure you understand clearly any medical concerns.

If there are none, as in the case of induction for postdates, a Biophysical Profile (BPP) might be a great tool you can use to your (and your baby’s) advantage.

Present the option as a compromise to your care provider. State that you are uncomfortable with induction for a non-medical reason. Agree to come in as often as they want you to, in order to do a BPP. Agree that if your score is a 6 or less, that you will be open to discussing induction.

A BPP score of 6 is considered to be borderline, so you still have room to compromise even then. Get a second opinion. Keep asking questions until you feel satisfied that you have enough information to make a fully informed decision. This means that you understand the benefits, risks, and alternatives available to you in your particular case.

One quick tip I give all my clients: Never make your final decision with your care provider in the room. You and your partner should be left alone. If you are not, it is your right to request that you be given privacy to discuss it. If possible, take 24 hours to decide. Then, once you know what you want to do, make your decision together, and be willing to accept any consequences that may result from it – good or bad.

Remember, you can only be induced if you show up. I strongly urge you that, if you are inclined to showing up for an induction, please make sure you feel very certain of the real reason, and that you are at peace with it.

If you were induced for postdates, and there were no other indications, was the BPP made available to you? What questions would you ask your provider in this particular scenario? What other compromises could you make with your CP in the case of a non-medical induction discussion?

Grace & Peace,
Tiffany

There’s more to Pitocin…

Friday, April 8th, 2011

First, read the following link, then come on back. Go ahead. I’ll wait.

Pitocin’s Untold Impact ~ Birth Faith

Pitocin – like any other drug – is a tool, morally neutral, with its own proper and improper uses. This post examines some emerging evidence of the role oxytocin plays in our lives. How synthetic oxytocin may hinder or help that is still being studied, but what’s coming out is like a big red flag that reads: “PROCEED WITH CAUTION!”

Never assume a drug is needed, based solely on someone’s say-so, and never assume the reverse. Examine your own case, have an open conversation with your CP, and listen to your instincts.

Pitocin might very well be needed, but that does not mean you should use it without knowing the risks, benefits, or consequences that may go along with it. Knowing those things will equip you to understand more fully what’s going on, as well as alert you to watch for long-term consequences, and may help you narrow down any issues you may have later.

It’s a tool – use it wisely, and own it. No apologies necessary for either road you choose, as long as you’re paying attention to the signs on the way!

The Most Important Piece: Following Up

Saturday, December 4th, 2010

This is the the introduction to a series of six posts, inspired by this post, in which I will be writing about the critical role your support team and place of birth play throughout your pregnancy, labor, and birth. Over and over again, we find that a woman’s satisfaction with her birth experiences has less to do with how much pain she experienced, or the method of birth. It has far more to do with her feeling of autonomy, and her feelings of being supported (or not).

Women who feel as though things were just “done to them” throughout the childbearing year, especially through labor and birth, are more likely to struggle with feelings ranging from dissatisfaction to outright depression. In contrast, women who feel that they were the ones making the decisions, and that those decisions were fully supported by those around them, especially their care providers, are the ones most happy with their births.

Epidurals, IV narcotics, massage, showers, and position changes are all well and good. Valuable tools for pain management, but it turns out that having these things available is not as important as a support team who strives to empower and encourage women by practicing true informed consent, including informed refusal.

When the decision-making power is put into a woman’s hands, and she understands fully that it is she alone, along with her baby, who lives with any consequences of her decisions, good or bad, birth can be the most empowering experience in a woman’s life – even if the physical circumstances are not ideal.

Inspired by my mother’s critical role in my births, I have decided to write a series of posts about the various possible members of a typical birth support team.

I’ll be writing first about various care providers, the general differences between them, and how to choose the one who best suits you. I’ll talk about your partner/spouse’s role, and how birth has the potential to strengthen the bond between you. Doulas, of course will have a post all their own, including how to choose one based on your individual needs. Last, but not least, I’ll write about childbirth education options, explaining their role, as well as how to choose a good childbirth education course.

Join me for the next few weeks as I gather my thoughts together on this subject – it is truly the Most Important Piece of your birth experience, and I don’t want you to miss a thing!

I’ll be linking each post here, so you can have them all in one place. Please – always feel free to post a comment or question, or email me.

The Most Important Piece Series