I attended a birth yesterday. My client (who was delivering her second baby)stated in her birth plan that she did not want the routine pitocin shot if she labored and delivered without an epidural, unless she was hemorrhaging. So she delivers her baby naturally (much to her surprise) and the doctor manoeuvers the placenta out (instead of just waiting for it to come...she was just-a manipulating that cord). Then the Dr. gives the order for the pit to be plugged into the heplock. My client got a horrified look on her face and started to speak up, but they weren't listening. It didn't help that she was, of course, in a bit of pain and taken very off guard by this. So I spoke up and said that her birth plan stated that she did not want the routine pit if she went naturally.
"Oh you don't want to hemorrhage. What you've been through is much worse than that pitocin. You won't feel it at all!!"
I asked "Couldn't she be monitored, and then if she shows signs of hemorrhage she could receive the pit?"
Dr. says sarcastically "Well, ANYTHING is possible. But oh look, there's some blood right there, see? You really need this."
Well of course she's bleeding. She just had a baby, but she was nowhere near hemorrhaging. I just don't think the doc wanted to stick around very long. Everytime she yanked on the suturing thread to rip it, my client jumped and cried out. The doc told her that she was just jumping from being touched and she didn't feel anything that was just done to her. ( <--me)
Both the nurse and the doc gave me a decent eval, but they were both put off that I pursued the pit issue by speaking up about the birth plan, and then by asking if she couldn't be monitored instead. I didn't get to mention it to the doc, but I did tell the nurse that for my 4th and 5th own births this is exactly what was done because my uterus does clamp just fine, and that the pit is indeed painful. It's bad enough to go through those afterpains without feeling like my middle is being sliced through with a knife. (I didn't say that...just my own comment here.)
I wasn't trying to make the doc look bad, but this was just one of a series of things either in her birth plan or her stated wishes that were just ignored. She walked into the hospital (we left the house at the first signs of transition) saying she felt like she needed to push. Nobody was there waiting so I walked ahead a little to flag someone that she was pushy. They totally blew us off. "Oh she's not gonna push! Everything's just fine!" I said "She's been in transition for over 20 minutes," and I may as well have had two heads...
Until they measured her at 9 with a lip and a bulging bag. Forced her to be on her back for the strip (that must have been at least 30 minutes in itself) and then wouldn't let her off the monitor when they didn't like the heart tones. WELL OF COURSE NOT. She was on her BACK! Dr made her be flat on her back for pushing so "baby would slide under the pelvis" and she wasn't comfortable that way. Then the pit thing...and you know, it was just ridiculous. It was pure CYA and nobody was interested in taking the time to let her body take its time to do its job.
Then they took forever to get her pain meds.
But...the pit thing...did I go too far? The doc suggested I should have talked to her on the side, but there was no time to talk to her on the side. She wouldn't stop running her mouth trying to distract my client from the pain and they weren't waiting to do the pit. It was so instantaneous I felt it needed to be addressed right there and not 20 minutes later when Dr. left the room. Kind of late, then. It's like "Gee doc, can we go outside and talk about that episiotomy you just did that my client doesn't want?" (that didn't happen..just an example) In the hallway would have been too late. I wasn't rude, but I was surprised that they just ignored her wishes in that respect and hoped to find some middle ground. When my client looked at me (with the "there is no way we're going to win this one" look) and said it was okay, I immediately stopped. I am, after all, working for her.
Thoughts?
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I don't know if I would have said "Couldn't she be..." b/c the language of it suggests you have a better idea (yes, I do take language very seriously). Perhaps saying "Would monitoring be an option..." But my point in speaking up would have been more to let my client know (subtle-like) that there was another possible option she could push for rather than to change a Doc's mind. My
As far as dropping it once mom let it go...GOOD JOB! Isn't that the hardest thing sometimes! It sounds like you certainly did right by mom. It is unforuante that sometime CYA is more important than people. Keep in mind if this doc sees a lot of epidurals (which is likely with the current stats) she/he? really might not know that pit hurts. So I like that you mentioned this to the RN.
p.s. have you read Born In The USA by Marsden Wagner?
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I agree that saying "Couldn't she be..." was probably what pissed them off. Doctors don't want a Doula stepping on their toes - not that you really were, but they could have taken it that way. I think it would have been less offensive to say something like "Do you want to discuss your options?" to your client. I like to tell clients about this before labor, so when something like this comes up and I say "Do you want to discuss your options?" they know that is their cue to tell the dr. they either want some time to think it over or that they want more info on their other options.
There really isn't much that *you* can do. Technically you are not supposed to make choices for your client or speak to the staff on her behalf. Next time try saying something like "Are you comfortable with having pit?" That gives your client (or her DH) a chance to stand up for herself without giving you a bad name at the hospital.
I agree with all the advice given, and I also agree that it sounds like you did a great job! I have heard of pit being routine in a lot of places, but I've never had it even mentioned to me at either of my births which were in two different hospitals, and I haven't heard of it at the hospital I currently teach at....I'm going to ask FOR SURE! I think the idea of teaching you clients those invaluable words, "I do not consent," is the most empowering thing you can do for them! I'm going to remind my my current client via an e-mail RIGHT NOW!
Ash
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Sorry to say you are her advocate without a voice. Your there to support her BUT distracted or not she was the one that must decisively say NO absolutely not. Yes she could have won but she had to do it or her husband. As a doula you really have absolutely no voice in the delivery room. Does it P---me off? yup but this is why role playing is a good idea for these situations. Talking to the mom directly ( with your prelabor coaching )she will know she needs to refuse in a loud enough voice so no one can say oh I didnt hear you. She doesnt HAVE to do anything they want to do to her but she NEEDS to be aware and that would be your most important job to be her awareness. She still has to be her own voice. What I hate is a woman in transition and just after delivering is in a vulnerable state of mind but still no one can speak for her. Isnt it hard to drop it when you know it isnt what they want? good on you for that.
Last edited by sldsheppard; 04-16-2007 at 09:39 PM.
Reason: punctuation
I have always understood it was not the doula's place to address the OB about the patient's preferences, but to remind the client to inform the caretaker of their wishes. I have stopped a CNM from clamping a cord too quickly by saying something like "Hold off just a sec on that" then addressing the client by asking quickly, "Didn't you prefer to delay the cord being clamped?" That way I felt I was only reminding the client to reiterate her preference, instead of stating it to the caretaker myself. Probably just a difference of semantics, but sometimes it can make the difference between whether they felt you were overstepping your bounds.
Is it speaking to the staff on behalf of the client when we are reiterating what the client has already stated in the birth plan? I always figured the birth plan is the couple speaking for themselves, especially at a time they may not be in a place to speak coherently.
It was such a split second thing--they had that pit hanging and ready to go. When the doctor said the word, that nurse had it plugged in and my client started to protest but then looked at me with those big eyes like "do something!" I maybe should have mentioned that English is not her first language, either, so it was a bit harder for her to speak up on her own behalf. Might the doc have given my suggestion as one of her options? Doubtful...but in that vein...
I agree about "I do not consent." I should have hammered that home. I agree that "Do you want to discuss your options" is a great cue, but in this particular case there would have been very little discussion. She'd have been pressured into one option.
I think another thing that did us in, in this case, is the the client didn't contact me until 2 days before her due date (and labor) and so the Dr. didn't have the birth plan beforehand, nor was it in her chart at the hospital. It was all new to them when we arrived.
Thanks for the pointers. Many lessons learned here.
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Oh boy, what a challenge huh, especially just meeting her. I always discuss prenatally that if I turn to the client and say "Dr. so and so is about to do xyz, do you have any questions?" that they can consider that as a point where they need to ask questions. If mom is not able to, then it is up to dad. But you had a good learning moment so it will eventully be benificial to future clients. The reason we don't tell dr. what is in the birth plan even, is that they take it out on the clients.
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Since you just met her a few days before the birth and English wasn't her first language I'm sure that made things a lot harder. But still, as a Doula, you are not supposed to speak to the staff on the client's behalf, that is her and her partner's job. You can only speak to your client. It sucks! I've been through it too and it annoys the hell out of me because sometimes caregivers take advantage of the fact that mom is in pain and not able to really fend for herself. The thing I stress most at prenatals (to combat this issue) is that I WILL NOT speak on my client's behalf. We set up a codeword or code phrase and I let her know that it is up to her or her DP to speak up.
You can get thrown out of a birth for pissing off the medical staff, and then you can end up with a bad rep at that hospital and the staff can make things miserable for you in the future. It stinks when you have to walk that fine line to defending your client's wishes and getting into trouble.
Yeah, I've already given the heads up to one of my next clients. And it's exactly what you said--they take advantage of the fact that Mom is in a ton of pain. (Then again, she was totally aware they were about to do something she definitely did not want, but I could see they weren't listening. grrrr) Of course not all docs do that. I've had good docs for the most part, but the majority of the staff on Sunday did not listen very well to my client. They just walked all over her at times...gave them an inch and they took a mile.
On a positive note: I was very impressed with the nurse who did the baby's vitals, weight, ointment, etc. She was very sweet and spoke to my client like she was a person and not another mom on the assembly line. She went through each point and asked what was okay and not-- the vit K, the ointment, etc.
My next birth will be at this hospital, but the caregivers are a practice of midwives. Hopefully that will make a difference.
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I had to deal with the same thing at my sister's birth, one of the nurses completely did not listen to my sister when my sister was yelling "ouch". All I could do was say "does that hurt? Do you want her to stop?" It was such an awful and helpless feeling. It makes me mad too. I completely understand your frustration.
Thx I couldn't imagine watching my sister being treated that way. How difficult for you
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Just to add a bit that might be helpful and at least is normally amusing. I talk seriously with dad about being the protector of the space. We discuss the difference between advocacy and speaking for the client (taking power away from them both). Then, to lighten the mood, after all, birth is a happy time and I don't want them to think they will always have to be fighting, I tell him, "If I look you straight in your eyes and raise my eyebrows up and wiggle them up and down, you know that something is going on or about to happen that you need to pay attention to." Then I wiggle my eyebrows at him.
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( <--me) 
It sounds like you certainly did right by mom. It is unforuante that sometime CYA is more important than people. Keep in mind if this doc sees a lot of epidurals (which is likely with the current stats) she/he? really might not know that pit hurts. 
So I like that you mentioned this to the RN. 
Aiden (2/03) and my heart baby (TAPVR) 
Evan (6/07)
