Decisions, decisions

amymaew · 01-04-2010, 10:15 AM

So, I was at a birth all day Saturday, baby girl born around 1am on Sunday. They called me at 6am Sat, I got to their house at 8am. They had called their dr's office to let them know labor had started before I got there. Around 3pm we went to the hospital, the nurse said she was 5cm. 5pm she said 8cm. I think she was just making numbers up, b/c client was acting like 1-2cm when we got there, and maybe 4cm at 5pm. (I say this retrospectively - keep following lol). 6pm same nurse said she was "really 8cm now, but if dr ____ checks you he'd say less b/c that's how he is". What, honest? Um, ok. So 8pm dr said she was 6-7. 10pm she was the same, and agreed to AROM after a great discussion about risks and benefits. Transition hits, we get her into the shower, she's coping beautifully, but after 45 min or so her ctx have really spaced out to q7 or q8. We get her back out of the shower and walking around, and ctx pick up. After about 3 ctx she starts saying "I don't want to do this anymore," her dh and I are talking to her, helping her, reminding her that this is transition... she starts screaming at us that she wants meds and says her code word. I go get the nurse, client chooses stadol. We go over the effects she'd feel from the stadol and how it works, nurse asks if she's sure she'd want that instead of an epidural, she still wants stadol. Falls asleep, wakes up around 12am screaming, but still out of it. She's 9cm, can't have more stadol, still is adamant she doesn't want an epidural, wants a paracervical block. Dr comes in, says you're complete, so there's no cervix left to get a paracervical block in. Would you like the epidural instead? She refuses, starts pushing soon after, has a baby a little after 1am. She was still pretty out of it after baby was born, and pretty much fell asleep as soon as they started weighing baby etc.

So, now for my question/discussion. As I was leaving, the dr was at the nurses station and asked me how I could deal with her so obviously in pain and not push an epidural. He said that any of his colleagues (and I fully agree with him) would have said "you need to get an epidural" because it seemed like torture. I said that I agree with him that an epidural would probably have helped her a lot, and she would have been with it when the baby was born, but they hired me to help them have a natural birth and I had promised them that I would do everything I could to get her there as long as she still wanted to do that. As soon as she used her code word, I went to get the nurse for her for pain medication. I told her the risks and benefits of all of the different options, and let her make her decision. He thought I should have pushed the epi a bit more. *I* think that when you make a decision for the mom it's a worse outcome in the long run because you're taking away her power kwim? And I told him that - that an epi would have been my choice in that situation, but I didn't know what was going on in her head, why she was so opposed to the epi, or a whole host of other things. So, what would you have done? When she said she wanted the stadol I did emphasis that she would probably feel drunk and out of it, and it would wear off, but she still wanted it. I feel like I did what they hired me to do, but I also feel like the dr is right - she should have had an epidural. But, it's not my birth, right?

turtlewomyndoula · 01-04-2010, 10:19 AM

I am a very new doula, but IMHO we are there to give the parents the information they need to make the decisions, not to make the decisions for them. I think you did everything right.

dawnb · 01-04-2010, 10:25 AM

I think you did what they hired you to do. What we think or what we think they need is irrelevant. it's them and she was given the information and made her own decision. Problem is, when the mother starts making her own decisions it takes the Dr out of control of the situation, to which he probably felt put out about. I think you did a great job talking to that Dr and explaining WHY you didn't make a decision for her

Good Job

medicinehatdoula · 01-04-2010, 11:17 AM

She got what she hired you for...you respected her decision by not trying to push YOUR perspective on her pain. There is a difference between pain and suffering - a hard natural labor often DOES look like torture to some but it's a different type of pain. If she was truly unable to cope, believe me, she would have asked for an epidural herself. Both of you did good!

MissMamey · 01-04-2010, 12:06 PM

I'm with everyone else. You did exactly what you were hired to do. Have you had a chance to talk with the mama since then and hear her take on the birth? Sometimes and epi can help things, but sometimes it doesn't and there is no way to tell who it is going to help and who it won't. I think that you handled the talk with the doctor very professionally and positively (even though I think it is kind of a punk thing for him to push you into a conversation like that, just my opinion

)

doulafava · 01-04-2010, 12:21 PM

My guess is that she is going to feel very proud of herself for avoiding the epidural. She knows it was available and obviously felt very strongly about avoiding it, for whatever reason. I would personally rather be completely out of it on Stadol than have an epidural for reasons that are pretty intense for me. Sounds like you did a great job.

happydoula · 01-04-2010, 01:10 PM

Quote:

Originally Posted by medicinehatdoula

She got what she hired you for...you respected her decision by not trying to push YOUR perspective on her pain. There is a difference between pain and suffering - a hard natural labor often DOES look like torture to some but it's a different type of pain. If she was truly unable to cope, believe me, she would have asked for an epidural herself. Both of you did good!

I agree with Loree 100% - there is definitely a difference between pain and suffering, and just because she looked to be in misery to you does not mean that she was. I'm so glad you were there to help her, or she might have been convinced to get something that she really didn't want, since the dr definitely didn't have a clear understanding of what she needed. Good job!

Joyce in the mtns. · 01-04-2010, 01:50 PM

Oh Amy... you did SO great for this lady.

What MORE could you realistically have done in this situation?

You're not a male doc who's mission it is to save women (from the "torture" of pain in childbirth)... so you can't come from that viewpoint about what you do.

In your shoes given the story you've related, I can't think of ANYTHING more that should, would or could have done.

And I mean that. You did what you were hired to do, and as long as the client feels fulfilled and happy with her experience then you are golden, m'Dear!

(Hey you're golden anyhow in my book

)

breezyinsc · 01-04-2010, 03:37 PM

I agree with all the PPs, that you Doula-d the heck out of this situation, and made us all proud by holding your own with the Dr. It sounds like he didn't fully understand your role OR his own role during birth---it's not anyone's job to "save" a woman from labor pain, unless she says she wants to be! You did just what you said you would do.

On a more personal note, I can totally relate to the bit about her pretty much shutting down once baby hit the table. I had a birth a month back that was very similar in the end. After Mama had done nearly 10 hours on Pit with AROM, she finally started asking for the epi. As they were prepping her for the big stick, she agreed to one last cervical check and --- surprise! --- it was transition talking and she was nearly complete. She pushed that baby ( all 8 lb 15 oz of her) out in 4 good pushes and then passed the heck out. I felt like garbage as soon as I left the hospital, torturing myself with the idea that I misinterpreted her suffering for very vocal coping and helped traumatize her by urging her on without the epi. I hardly slept after that birth.

I went back to the hossy the next day, about 10 hours postpartum, and she was GLOWING. She was SO incredibly proud of herself, and asking how she could become a Doula

Give this Mama time to digest. I didn't believe all the AD ladies when they told me that my client would come around, but yours will too. And she will thank you for helping her have the birth she wanted to have.

You were amazing! And you give Doulas such a good name. Keep it up, sister. You're making us all proud and our profession is honored by your work.

Comfy · 01-04-2010, 04:22 PM

I believe you did exactly as you should have. You supported her. You listened to her, you did not make decisions for her. If she wanted an epidural she would have asked for one.

When you have your PP visit, I bet she will be quite happy with her birth. We all know labour is hard, and can be quite primal and vocal. That does not mean she was suffering. She was coping , and you helped her to achieve what she wanted.

doula Michele · 01-04-2010, 06:40 PM

I agree with everyone else. You did not push your opinion, nore did you deny her what she wanted.
You did exactly what she paid you to do. I am sure she was happy in the end.

bbabs · 01-04-2010, 10:10 PM

I'm so glad that conversation happened and you felt confident enough to share with the Dr. maybe he will really think about your response and start on the path of realization that mom's should be the one's making the decisions!! Great Job!!

DoulaCindy · 01-04-2010, 11:55 PM

Sounds like you did a great job! I hate stadol. I've had it myself, urged to do so by a doctor that was bothered by the way I was coping. Never again! On the other hand, I've seen moms do great with Fentanyl (sp?). Afterwards the moms said "What was the name of that stuff they gave me? It was perfect! It just took the edge off and let me doze a little between contractions. It was exactly what I needed!" They didn't have that loopy feeling that Stadol seems to leave women with. And the moms were still very proud not to have had the epidural.

You sound like an awesome doula!

WendyLou · 01-05-2010, 12:27 AM

I agree that you did a great job and I think it's great you were bold with the doctor.

Personally, I love Stadol, have used it several times, but not at a full dose. Half and quarter doses are very effective and don't have all the side effects. Just FYI.

sunshine · 01-05-2010, 12:42 AM

i agree w/ all of the above posters that you did a great job amy. i hope this mama appreciates how you respected her power.

sorta OT:
why a sense of accomplishment w/ getting stadol or fentanyl but not an epidural? why the perception that an epidural is a less natural birth than one w/ narcotics? (not wanting to pick on anyone - just truly curious about people's perspectives) why afraid (like amy's client???) of an epidural but not afraid of narcotics? i really want to understand this better because i'm scared to death of all of the above (as a birthing woman - not a doula) and one would not have seemed "safer" or "less" than the other. as a woman who wanted a natural birth, narcotics would have been just as disappointing for me as epi.

as a doula, i've seen epidurals be helpful many times. narcotics are used much less frequently here and i've never had a client choose them. i've had students, and they've never been happy w/ the result.