Thursday, May 31, 2012

"Just in Case" Something Goes Wrong

The hospital doesn't always reduce fear. Many times it creates it, amps it up, takes it to the Nth degree. Women choose to birth in a hospital because there is that nagging fear that something bad will happen to them or the baby and they want to be near an emergency facility that can provide immediate assistance... "just in case." Society has told them that birth is painful and risky, and television and movies constantly show the doctor swooping in to save the day.

Sometimes being in the hospital is what a woman needs to have their ideal birth, because if they weren't in the hospital they would not have a good birth experience. Worrying about the health of the baby. But much of the time a hospital just takes that feeling of fear and runs with it. It will start with the nurse telling her that they have to keep her on the continuous fetal monitor so that they can make sure the baby's heart rate is where they want it to be. Now the mom is worried about the baby's heart rate, and dad can't stop staring at the monitor (instead of his partner). Then, even if the baby's heart rate is fine, they still insist on monitoring it all the time, "just in case." So the whole experience becomes ruled by "just in case." Never mind the fact that continuous external fetal monitoring is not evidence based. Hospitals are scared, doctors are scared, nurses are scared, women are scared, and families are scared. You are being told that you have to be on the monitor so you are too afraid to take them off to urinate without permission. You are too afraid to stand beside the bed instead of lay down.
http://www.mybirth.com.au/where.html

We expect our bodies to nurture and grow our baby for 9 months while we are pregnant, and if something bad happens we would go to the hospital. Same goes for birth. It is a normal process that generally goes right. And it something happens, we can go to the hospital. Bad things don't just happen during birth, they can happen during pregnancy, too. And postpartum! and throughout the baby's whole life! And we'd go to the hospital if something happened.

I have been in more than 8 different hospitals, and a few more than once. I know what this creation and growth of fear feels like. You can feel the shift in the room when the nurse or doctor explains something to the parents that makes them freak out. Baby's heart rate indicates the baby is sleepy, so that means constant monitoring in the bed (why?). They go into detail about how the baby is going to have a shoulder dystocia if they let her labor any longer on the epidural (what?), how if she hasn't had the baby by now it is probably too big for her pelvis because she is not following Friedman's curve (also not evidence-based, see note below for an explanation if you don't know what this is). They freak mom out with stories of how a shoulder dystocia means doctor has to pull on the baby and sometimes it causes nerve damage or break the baby's clavicle (shoulder dystocia does not always mean that. There are maneuvers mom can do to help the baby out). Wouldn't that affect your decision? How could you not make a decision based on fear for the baby after hearing something like that?

I consider myself highly informed about birth, and in such a situation I may be able to call that BS and refuse whatever they are trying to talk me into. Which is why I am a big proponent of women being as informed as possible! But even a highly educated, empowered woman becomes vulnerable and emotionally malleable during labor. And she may freak out when she hears that and not be able to advocate for herself. It's hard! It really is. I just hope that many women think back on their birth experiences later, when the baby comes out healthy and happy from a vaginal delivery during which they were making her fear for the baby's health the whole time, and thinks "what the hell were they talking about?"

And women aren't just asking for freedom of movement and intermittent monitoring or drug-free births or even just vaginal births because they "care more about the experience than the baby," as many jaded providers might believe. It is because the evidence shows 1. that these things make a labor less painful, less likely to stall, or are more healthy for the baby or the mother, and 2. that a woman's birth experience is remembered for the rest of her life. Research proves all of this. But many times nurses or doctors will have seen too many (true or iatrogenically created) emergencies and they are scared, so they want to make the mom scared, too.  When a mother makes a request to not have an epidural, the care providers feel they have to scold the mom, use their authority, get defensive, and create fear by saying they are going to do whatever has to be done for the baby. Obviously the woman would do anything to assure the health of the baby! She never said she would refuse a c-section if the baby's life was in danger, or that she would choose her preferences for a drug-free birth over her own or the baby's safety. A mother would certainly consent to birthing her distressed baby quickly, even if it meant a c-section.

I think its also important to note that even if there was an emergency situation that required surgery as fast as possible, most hospitals don't have that emergency staff always on-hand. Especially at night and on weekends, there is not always an anesthesiologist or an available obstetrician in-hospital. Many times they have to call the doctor, who just has to live within 30 minutes of the hospital come to perform the surgery. This isn't something we think about when we are birthing in the hospital, where we assume there will always be emergency care on-hand to take care of a situation within a 1 minute or 5 minute space of time. Unfortunately, this isn't true (and is one of the main reasons why doctors won't do VBACs). As Stephanie writes,
"I know you like to advertise yourself as being ready for an emergency at any moment…you say that being 15-30 minutes away from a hospital can be the difference between life and death! And yet….you ban VBAC’s because you don’t feel you are capable of dealing with the 0.1% chance of a uterine rupture since you don’t have an anesthesiologist as well as surgeon standing by immediately? If that’s the case…how are you prepared for ANY obstetrical emergency??"
One of the things that also bugs me about all of this is that the hospital is not only creating fear, but creating the emergency. That's what iatrogenic means - resulting from the activity of physicians. All the monitoring, staying in bed, not being able to move, eat, having to always "do something" like rupture membranes, pressing for pitocin for a faster labor, active management of the third stage... all of that causes harm for the baby and mother. Now I know that there are situations where the pitocin helped not hindered, the epidural was perfect and the baby was born easily through the vagina with no major adverse effects, etc, but more often than not they are associated with negative effects.

Additionally, many care providers encourage their patients to labor at home as long as possible, or until their contractions get to a certain point (like the 3/1/1 rule, which I hear all the time from parents). This is especially recommended if the mom wants a natural birth, and sometimes even told to women who want to successfully VBAC.  But doesn't this seem contradictory? Physicians say you have to be in the hospital to have your baby just in case something goes wrong, but then they say to labor at home? Is is not labor, then, that's dangerous, but just the birth? And if it is just the birth, then why monitor so much in the hospital? But isn't laboring at home the same as a home birth? And wouldn't that be better to do with a trained midwife who can recognize a need to transfer to the hospital?


Now if you DO want pain medication, obviously some of these points don't refer to you. For pain medication you do have to be in the hospital. But if you want a drug-free birth, being in the hospital can just cause a lot of increased fear and increased risk in many ways, and may the benefits may not outweigh the risks compared to a home birth. Or even just laboring at home as long as possible.

Much of the monitoring, etc occurs because hospitals fear for their own liability, not because it is evidence-based or best for the patient. I encourage you to keep that in mind when a doctor or nurse is trying to explain to you why you "have" to do something (you never HAVE to do anything, you can always say "I do not consent" even if they use the phrase "have to"), that it may be mostly motivated by protecting their assess ("look, we monitored! we can't be held responsible!"), and not your health or comfort. Or even by their schedules (doctor has somewhere to be at 6pm, has another woman in labor at another hospital that he has to get to, etc).

I know we live in a "just in case" world, and it's hard to shake. We lock our doors and install alarm systems "just in case," and it makes sense. But there are other things we can do for that "just in case" instinct that we are not. It is not recommended by physicians that a woman have a birth kit ready at home in case she has the baby faster than she can get to the hospital and she has to catch her own baby. We don't tell women to have all these things on hand in case the baby is born in the car or on the toilet, and we don't train partners how to catch or resuscitate babies. But maybe every mom should learn how to resuscitate a baby, "just in case."

This post has been a little bit all over the place, but I wrote it to express my frustration over what I see in hospitals and the way women are spoken to while in labor. This isn't necessarily advice or gospel, but just how I'm feeling lately!



Friedman's Curve - A depiction of the progress of labor used to facilitate detection of dysfunctional labor. Basically it is cited as a woman must dilate 1 cm/hour.
A study found that a wider range of "normal" was found, and that primiparous women remained in the first stage of labor for up to 26 hours with no adverse effects to mother or infant.
A recent systematic review found that 1.2 centimeters per hour is the mean, not the slowest, and that nulliparous women with spontaneous labor onset have longer "active" labors and therefore slower dilation rates than are traditionally associated with active labor.
Research and many professionals in obstetrics agree that Friedman's curve is an obsolete approach to labor assessment. But I just heard it cited 5 days ago as a reason a mom wasn't laboring fast enough.

3 comments:

Sally Johnson said...

A few months ago my daughter had her first baby. She decided to research about having a doula. After a little research she found the right doula for her. She had a great child birth experience because of it. And she had a healthy baby girl!

LactoDoulaDrPH said...

Thanks for your post! It was informative, passionate, eye opening, and validating. I wish more women (and their partners) were armed with the information they need before they embark on their pregnancy and childbirth journeys!

Anonymous said...

It's not *just* if the laboring mother wants pain medication: it's also if she has any pre-exisiting health conditions. Those with which I live could very, very easily turn pregnancy and birth fatal for me. They very nearly killed my mother and my grandmother.

So maybe home birth is great for some people, but please don't forget, as you push it, that there are a hell of a lot of us who aren't as fortunate as you, and who will deliver in a hospital because our lives are paramount to us.

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