Standard of {Your} Care

The Stir on  cafemom came out with this article you can read below and I desperately wanted to leave a comment but what I had to say was too long. I felt this warranted a blog post! 

There is a term often used in our society that I have come to question. That term is "Standard of Care"

Initially, I think of my care provider taking this approach to care for me in the best way s/he knows how for my situation. What this term really means is, 'this is the problem, this is the solution' across the board.

 Pregnancy and birth are such intimate times and each woman and baby so unique; is this really the kind of care you want to receive. Standard not being what's best for you and yours but what's most commonly used (not necessarily evidence based or the best) throughout America.

I urge you, don't accept merely the "standard of care" but strive to discover what is best for you, as an individual, in your personal life and circumstance, creating the standard for your care.

Be empowered with informed choice and refusal. 

I have two overused and unnecessary pregnancy procedures to add to this list by Michelle Zipp- vaginal exams and IV fluids. 

Most importantly vaginal exams. They are not necessary in pregnancy or labor and can lead to the overused, and often inappropriate, diagnosis of "failure to progress" in labor. In pregnancy, many women think they need to know if "they're getting close" by vaginal exams as they near their due date. Getting a vaginal exam does not predict when you'll go in to labor. As a birth doula, I've had clients be at 2cm for weeks before labor starts and clients who weren't "showing any progress" go into labor the next day. I put "showing progress" in parenthesis because there is so much more going on in labor than a cervix is telling and the cervix dilation is the last thing to happen. In labor, not only is your body preparing to open and birth your baby, but the baby is preparing as well; it's an delicate dance, best left undisturbed. Maryn Lyster describes birth as "being, not doing."

Now along those lines of the position of baby- I've read a lot of comments in the original article of fetal monitoring and fear!!! We don't have to have the electronic fetal monitors and not having them should not create fear.  A hand help doppler or fetoscope works just as well. For years and into this day and age, women safely deliver babies at home without these efm's. Not only can electronic fetal monitors can be read wrong but they also restrict your mobility. Did you know that your position can also affect baby's heart rate? For example, if you're lying on your back, which you are doing quite often when on the monitors, you can be compressing the baby's cord which can cause a dip in the heart rate. Too often, unnecessary panic and cesareans are caused by these monitors. Before panicking, try changing positions. Also consider and internal monitor if you're being faced with a cesarean. Also consider, are you being directed to push and doing so on your back? 

This brings me back to the vaginal exams. Pushing should be left to the experts- the laboring mother. If you have the urge to push, you're care provider or nurse may want to make sure you're fully dilated- whether you allow this or not is up to you, but if you have the urge, you have the urge and if you don't, you don't! Quite often while attending births as a doula, I see [too] frequent vaginal exams during labor and then mother reaches 10cm and she's given "permission" or sometimes directed to push before she has the urge. As I said earlier, there is so much more going on than cervical dilation, including the position of the baby. Perhaps, though mom may be fully dilated, the baby is not in the most optimal positioning for pushing or perhaps she's lucky enough that her body is allowing a break before the 2nd stage. Going ahead and pushing on command could have a negative affect on baby and make it harder for mom, when she could be enjoying this nice break or using this time to re-position herself or work with her doula or partner, trying rebozo sifting or other methods of encouraging the baby to get into position.

IV's - when and why?

IV fluids are needed if you plan on or need an epidural. The hospital will administer fluids, via and IV, to help reduce the likelihood of your blood pressure dropping too low upon administration of the epidural or spinal block. IV's are also used to administer medications such as pitocin or narcotics.

If you don't plan on any of these interventions and are low risk, you don't need the IV. The hospital will encourage you to have a heplock, "just in case" but think about it- Getting the heplock is not going to administer the fluids, that you probably don't want any way, it's just there. So, it doesn't have a head start on much "just in case" and if you're trusting the hospital to be a safe place for the birth of your baby, I hope you trust the skill of the personnel enough to place an IV should the medical need arise.

Use your best judgement; do what's right for your body and your baby, know your options, be prepared for your birth- don't skimp on the childbirth education. The conclusion of all of this is to trust birth and to trust your body. Too often these "standard of care" medical procedures cause the very problem you'd like to avoid. If you are low risk, a low intervention birth is probably in your best interest. 

How will you be empowered on this Journey of Life?

Birth of our Society

The quality and outcome of childbirth in our society is in need of reform.  This is a life changing event for a family and should be recognized as such. Throughout time our statistics in health outcomes have declined along with the quality of care a woman receives.  Options have been stripped, the compassion and art of birth is being lost in the rush of our culture. Today it is common to find birth rushed and controlled and being born of those demands we continue to live those demands. [This is no way to live!] We need to recognize this as a problem and begin remember the midwifery model of care and give birth back to the mother.

The birth of her baby will impact a woman for the rest of her life; this occasion will affect what kind of mother she will be, the kind of lover she is and ultimately determine how she perceives herself.  If her birth experience left her feeling strong and able she will be empowered and confident; birth matters.    Ask any woman her birth story and you’ll see the flood of emotions come back to her.  ACOG defines delivery as the extraction of a fetus.

The state of maternity care in the United States renders us third highest of developed nations for maternal mortality rate.  In a nation where we flaunt our technology this statistic is shameful.  Our cesarean rate is 32% when the World Health Organization recommends no higher than 15%. Hospitals emphasize standardized care across the board for this personal life event.  Putting a woman in a hospital, treating her as if she has an illness, completely undervaluing her power and ability to birth her own baby is not the appropriate approach to birth.  Maternity care should protect mothers from complications rather than creating them.  Far too often care providers are managing birthing women in the most time efficient, convenient manner; cost being a huge influence of how they provide care and further influence coming from insurance companies and new technology that is released before its full impact can be determined. Indeed, we are seeing today the effects of the epidural and still seeing more negative outcomes than positives as a result of standardized continuous fetal monitoring. These fetal monitors interfere with the ability to labor comfortably; whatever happened to women being attended individually and monitored by their personal birth attendant?  This can’t be done in a hospital when the demand is for more patients, nurses stop by for scheduled readings and care providers step in to “deliver” the baby or if the machines determine a problem.  In other developed nations such as Holland, home is the place of choice for birth, yet here the first thing we do is call a trained surgeon and pick a hospital.  At home we can’t control labor and birth like we can in a hospital but that’s just the thing—like Mother Nature, birth is not meant to be controlled.  In a hospital, a woman must be firm in her request for staff to ‘sit and wait’ because it’s so common for them to speed things along, manage her pain “the easy way” and turn the bed for the next patient. Those who are aware of their options have to exert great effort for what they want, negotiate to prevent what they don’t want and constantly repeat their desires.  If health care providers were to protect the mother’s space, being there when needed to assist as she birthed, patiently sitting on their hands when not needed, birth could become the sacred, peaceful event it was meant to be.

Today, the media has instilled into women fear surrounding birth. From the introduction of hospitals, came a veil, separating fathers for a time, and stripping birth from its normal role within the family when girls once saw birth many times prior to their own experience. In this harsh environment complications were born where we sought to make things easier.  Doulas are said to create a buffer for this harsh environment as well as provide continuous emotional and physical support for the mother and even for the father allowing him to participate at a level that he feels comfortable.  Prepared childbirth aims to give women understanding of the physiological process of birth, understanding the hormones, emotions, variations of 'normal' and their options. There are various methods of prepared childbirth that equip women with means of coping and accepting their labor in a positive, relaxing way.  The goal of prepared childbirth is to take away fear and instill confidence; doulas facilitate this preparation. Unfortunately only 36% of women will take a childbirth education course and only 3% will use a doula.  Fear of birth results in negative outcomes, while acceptance is attributed to positive birth outcomes. 

In most cultures midwives provide the primary care for expectant mothers and obstetricians are there in case of complications.  This is not to say that all ob’s are medicalized but that is their training—in managing complications prenatally and in labor & delivery.  In the 1920’s when birth moved into the hospital, doctors slandered midwives to gain more patients and attract attention to their “nice, shiny facilities”; there became a rift between these two birth professionals.  Across the United States midwives face animosity from obstetricians and hospitals when in fact, their goals should be the same—a healthy mother & baby and a satisfying birth experience.  The birth experience will influence bonding between mother and baby as well as overall maternal health, therefore, this aspect cannot be ignored.  The problem remains in the great divide between obstetricians in midwives.  It is immensely important that we bridge that divide as well as heed to the “do no harm” creed in obstetrics care. It would be prudent of us to follow suit of those cultures where birth is attended by a midwife and medical interventions and ob’s come in play as necessary.  Birth is a natural life event, an important part of the Journey of Life, and should be treated as such; it’s not a money-making endeavor. 

Informed Consent

According to the American Medical Association, informed consent

is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.

In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

• The patient's diagnosis, if known;
• The nature and purpose of a proposed treatment or procedure;
• The risks and benefits of a proposed treatment or procedure;
• Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
• The risks and benefits of the alternative treatment or procedure; and
• The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

A key factor in the case of labor and birth would be timing.  Be sure to ask if the situation is urgent or if the procedure can wait.  Consider what is being used to indicate timing.  For example, does an electronic fetal monitor indicate baby's heart rate is dipping?  Note your position.  Are you lying on your back?  This position cuts off oxygen to the baby which results in a stressed fetal response,  Try lying on your left side and see if this fixes the problem. 

Continuous monitoring became a standard obstetrical procedure before studies could show if the benefits outweighed the risks, and without clear-cut guidelines on how doctors should interpret the findings. (Brody, 2009)

Evidence shows intermittent auscultation is the best way to monitor baby during labor.  Were you told this or of the risks of cEFM, including increased vacuum extraction, increased incidence of cesarean section without a reduced risk in perinatal mortality?  I have seen all too often women whose doctors told them they'd have the freedom to move during labor only to find once in the situation they were restricted far more than they would have liked and had been led to believe by the monitors.  In the examples above and below, restriction to the bed could be the cause of the 'problem.'

Perhaps your labor seems to not be progressing.  Before you sign the consent for a cesarean , consider dilation is not the sole purpose for contractions.  Labor is a delicate dance, according to an article in Midwifery Today,

What a contraction is doing is always ahead of what a cervix is telling.

There is purpose for pauses in labor, yet some medical professionals tend to jump the gun and assume labor has stalled, opt for a c-section and jot down "failure to progress" on your medical record. Easy, safe, fast fix.  Though it's not always safe.  Let me remind you, to be informed you must be aware of the risks and benefits of accepting the intervention as well as declining it.  Informed consent should not be fear based, yet the laboring woman is told you're not progressing, something is wrong.  This creates fear & anxiety, which are not conducive to labor and birth, and also puts the pressure on the laboring mother to "hurry up and dilate" -a bodily process she cannot directly control. 

Labour in a clinical environment may undermine women's feelings of competence, perceptions of labour, confidence in adapting to parenthood and initiation of successful breastfeeding. (Hofmeyr, Nikodem et al. 1991) 

This referenced study exhibits some of the risks of laboring at a hospital.  A hospital 'requires' at least one cervical exam and the risks explored here include unnecessary surgery, postpartum depression and more.  Were you informed of this?  Were you informed of the risks and benefits of cervical examines?  Did you know you have the option to say no.  Remember, it's your body, your birth experience.  Keep calm and birth on!

A person must be "in a reasonable state of mind" in order to give informed consent.  A woman in a non-medicated labor is in a primal state- this is not of reasonable mind.  When in this state, being coerced with fear does not equal informed choice.  It is essential to educate yourself on labor and birth, create a birth plan, get to know your care provider and hire a doula- this person can advocate for you and help you remember your options and assist you in making informed choices when emergencies arise.  Labor and birth are unique to each woman and each birth yet too frequently women are treated on the same basic template.  When something arises that an intervention is suggested, a woman in labor is not necessarily of a "reasonable state of mind" and her partner may become intimidated, stressed and concerned for her well being and that of the baby.  A doula comes equipped with a clear mind in the time of need and knowledge of the physiology of labor and birth, of various medical interventions and of hospital protocols.  Using a doula facilitates informed consent.  She is not there to make choices for you but to inform you of your choices.

Evidence shows that using a doula decreases the request for epidurals.  When a woman asks her doctor about pain relief it isn't very often they recommend a doula, most frequently they'll mention narcotics and epidurals.  Ask about the risks and benefits! And don't accept the answer that there aren't any risks- it's simply not true. 

Empower yourself on this Journey of Life with education to understand all of your options for labor and birth.  Be informed when you consent!