...it's important to try to remember the times when I may have done something that changed one person's mind or experience a little bit.
The normal newborn exam. At my most recent birth, the family doctor wanted to examine the baby, but the mother was reluctant to give her up. I asked if it could be done where mother could see. The doctor said sure, and motioned to the infant cart, which was several feet away against a wall behind the mother's head. I asked if it could be moved closer. The nurse pointed out that it was under the warmer, which was bolted to the wall.
I mused about how at home they do the newborn exam beside the mother on her bed, but too bad that the hospital bed was too small for that. The doctor then suggested that perhaps he could do it with the baby right where she was - skin to skin with her mother. Sometimes the indirect method works better than my asking for something for my clients outright. I wonder if he'll think about doing that at his next birth?
Pushing. Once, I had a client in hospital with a medical student observing. She was beginning to push, and needed to pee. The nurse, per protocol, did not want the mother pushing on the toilet - they always think the baby's going to fall in. With a first baby, when a mother's just begun to feel pushy, the risk is vanishingly small. I said something of the sort, and the nurse agreed to let the woman go as long as she promised not to have the baby there. :-)
When she came out of the bathroom the mother asked me for help understanding a squatting position. Before she got back on the bed I demonstrated squatting by holding onto the bed and squatting on the ground. I intended to help her do this on the bed, but she got right down beside me and began to push in a very focused way. The nurse was a bit flustered, and whispered that she was concerned about not being able to see what was going on. So I turned on the mini maglight that hung around my neck, and the nurse and I proceeded to sit or kneel on the floor and watch the mother's perineum by flashlight.
I was thrilled that all of this was happening, but even more thrilled that it was happening in front of a med student. She got to see a midwifery-style labour in the hospital that night. I was pleased that we had a nurse who was flexible and willing to let curiosity override custom.
IV for antibiotics. GBS protocols have been a moving target over the last ten years. A few years ago the standard of care at the hospitals around here was to start an iv in active labour, hang a bag of antibiotics, and keep the iv running with ns or rl for the rest of the labour. Then I attended a home birth with a client who was GBS+. When the time came, the midwife started an iv, ran in the antibiotics (hanging the iv bag from a coathanger hung on the edge of a door), and then disconnected the iv tubing and capped the iv port. Four hours later, she reconnected the iv for the next dose of abx.
So, the next time I had a hospital birthing client who was GBS+, I told her this story. She asked her ob about it, who said "I don't see why not" and placed instructions in her chart. From then on I encouraged every client to talk to their doctor about this option. At first the nurses thought it was odd, but they are now encouraging it for clients who want an unmedicated birth and want their freedom of movement. I'm sure hospital policies have not changed because of my small handful of clients, but I'm sure their requests didn't hurt.
There must be more - I'll try to dig one up whenever my flagging spirits need a boost.
Friday, May 22, 2009
Wednesday, May 13, 2009
Maternity care where I live
We all know that choosing your doctors is important. You may be looking for different things from different kinds of care providers. If you're looking for a heart surgeon, you might want someone with lots of experience in the procedure you need, who's affiliated with a hospital with an excellent reputation, and if s/he'll also take the time to explain things to you it's a bonus. With a shrink you want someone with whom you feel safe, who's patient, and who won't talk down to you. With maternity care providers you want someone who will take the time to really answer all your questions and who shares your philosophy of childbirth. All the books say that this is the most important thing you can do to have the kind of birth you want.
With most specialists there is an ongoing relationship. If you do not feel comfortable with a doctor you can ask for another referral, you can change. With an obstetrician there is an ongoing relationship during the pregnancy, but that person may not be there for the birth. When you're giving birth there is really no option to cancel the appointment, walk out, and start looking for a different doc.
In Toronto, Ontario in the current health care environment, family doctors, obstetricians and midwives are all in short supply. Women are rarely able to interview care providers and choose one who suits them and their family - care providers just don't have time because they're struggling to see the patients/clients they already have.
Many women who would have liked to have a midwife find that if they wait until six weeks of pregnancy (which, let's face it, is when many of us are just starting to realize we've missed a period - not all pregnancies are planned to the minute) then the midwives are all booked up. There may be waiting lists, but no assurance that your name will ever make it to the top. If you do get an appointment, you take the first midwife you can see, because if you don't book with her immediately you might miss your chance. You might not think to ask about holiday schedules, about off-call time, about the chances of having your primary midwife at your birth.
Doctors are run off their feet. With the encouragement of the government and to try and balance the demands of an over-full obgyn practice and a personal life, most doctors work in group practices of varying sizes. Everyone in the group shares call. Some of my clients have doctors who are in groups of 10, 12 or more. So, their chance of seeing their own doctor on the day they give birth is 1 in 10 or worse. Meeting the other doctors in the practice is impossible under these circumstances. There are a small number who make a point of attending their own patients - some of them are extra dedicated, and some just don't play well with others.
So, that means that by far the majority of my clients are attended in labour by people they've never met before. Those who were aware that this would be the situation from early in pregnancy often don't bond with their care providers: "oh, he's okay, but he's not going to be there anyway so it doesn't matter".
As a doula I find it really frustrating to try to help families achieve the kind of birth they want. I can help them have good conversations with their doctor, I can help them write a birth plan and have the doctor give feedback, perhaps put it in their chart, we can luck out and get assigned a nurse who is interested in hypnobirthing/natural childbirth/etc and happy to support a calm environment, and then you can have an on call ob who walks in, flips on the lights, orders a woman onto her back and starts managing the birth according to their standard high-intervention operating procedure.
Even with midwifery care you can run into disconnects. A couple of times I've had clients planning water births who happened to go into labour on a day when their primary midwife was off call, or had another client in labour. The midwife who arrived was not well known to the client, was nervous about water births, and undermined the client's plan.
I can help clients plan, I can help them access information and discover options they didn't know were available. I can help them express their needs and wishes. But I can't change their birth place, their care provider or the underserved health climate we live in. If any of you have any ideas on how to work this way (other than UC!) please share.
With most specialists there is an ongoing relationship. If you do not feel comfortable with a doctor you can ask for another referral, you can change. With an obstetrician there is an ongoing relationship during the pregnancy, but that person may not be there for the birth. When you're giving birth there is really no option to cancel the appointment, walk out, and start looking for a different doc.
In Toronto, Ontario in the current health care environment, family doctors, obstetricians and midwives are all in short supply. Women are rarely able to interview care providers and choose one who suits them and their family - care providers just don't have time because they're struggling to see the patients/clients they already have.
Many women who would have liked to have a midwife find that if they wait until six weeks of pregnancy (which, let's face it, is when many of us are just starting to realize we've missed a period - not all pregnancies are planned to the minute) then the midwives are all booked up. There may be waiting lists, but no assurance that your name will ever make it to the top. If you do get an appointment, you take the first midwife you can see, because if you don't book with her immediately you might miss your chance. You might not think to ask about holiday schedules, about off-call time, about the chances of having your primary midwife at your birth.
Doctors are run off their feet. With the encouragement of the government and to try and balance the demands of an over-full obgyn practice and a personal life, most doctors work in group practices of varying sizes. Everyone in the group shares call. Some of my clients have doctors who are in groups of 10, 12 or more. So, their chance of seeing their own doctor on the day they give birth is 1 in 10 or worse. Meeting the other doctors in the practice is impossible under these circumstances. There are a small number who make a point of attending their own patients - some of them are extra dedicated, and some just don't play well with others.
So, that means that by far the majority of my clients are attended in labour by people they've never met before. Those who were aware that this would be the situation from early in pregnancy often don't bond with their care providers: "oh, he's okay, but he's not going to be there anyway so it doesn't matter".
As a doula I find it really frustrating to try to help families achieve the kind of birth they want. I can help them have good conversations with their doctor, I can help them write a birth plan and have the doctor give feedback, perhaps put it in their chart, we can luck out and get assigned a nurse who is interested in hypnobirthing/natural childbirth/etc and happy to support a calm environment, and then you can have an on call ob who walks in, flips on the lights, orders a woman onto her back and starts managing the birth according to their standard high-intervention operating procedure.
Even with midwifery care you can run into disconnects. A couple of times I've had clients planning water births who happened to go into labour on a day when their primary midwife was off call, or had another client in labour. The midwife who arrived was not well known to the client, was nervous about water births, and undermined the client's plan.
I can help clients plan, I can help them access information and discover options they didn't know were available. I can help them express their needs and wishes. But I can't change their birth place, their care provider or the underserved health climate we live in. If any of you have any ideas on how to work this way (other than UC!) please share.
Really back now - and the baby's okay
I attended my first birth last week - my first birth since coming back into doula work after nearly two years off. Lovely family, very inquisitive, worked hard to get the birth they wanted. Nearly sabotaged by an ob resident who just was not on the same page at all.
It really does feel like I never left. I've been wondering what sort of changes I would see in the hospitals I go to, the care providers I come in contact with. I was very excited about this birth because the parents were just so willing to ask questions, do some research, do some work and keep their experience and their baby's experience of childbirth as centrally important concepts.
Sometimes people have difficulty getting it, though. Even a family member, when I was talking about my disappointment in the care my clients received, said "but was the baby okay?". Yes, the baby was okay - of course the baby was okay. The doctors want the baby to be okay, I want the baby to be okay, and I guarantee you that the parents want the baby to be okay more than the rest of us put together. If it happened that the baby was really not okay, the parents would be more than willing to change their plan and do what was necessary. But that's not all that matters.
Have you had an experience with a doctor who was overbearing, who tried to scare you into compliance, who steamrollered over your requests because "that's the way we do it"? Were you okay? Were you okay physically? Were you okay emotionally? If the answer was yes to the first but no to the second, did you go back? Many of us have changed specialists because we did not feel emotionally okay with the person. Sometimes we're able to separate these feelings to the extent that we realize the person is probably competent and will do their job well, but we just don't like them. Sometimes we can't separate those feelings: a doctor who makes us feel bad emotionally may very well leave us feeling that we can't trust their clinical judgement, and we just don't feel safe with them.
Feeling safe is critical in birth. Fear and anger flood the body with the kind of stress hormones that can slow labour, create tension in the muscles and make it very difficult for a woman to release - or even want to release - her baby out into the world. Late in labour, fear for her child's safety can make a woman push in ways that may be designed to get the baby out faster, but which compromise her oxygen supply (and thus the baby's), increase her risk of tearing, and affect her ability to welcome her baby with openness and joy, rather than just relief.
On the provider's side, fear and anger make a patient/client suspicious, resistant, and disconnected. Why on earth would you want that? If you can gain compliance, get your patient to do things your way, you may have a good outcome: a physically healthy mother and baby. But what about their emotional health? What about your emotional health? It can't feel good to be having to bully patients into compliance. It can't feel good to have families toss you out of the room and know they're discussing your actions in your absence. On paper, the baby may be okay, the mother may be okay, your actions may be okay. But is that really all that matters?
It really does feel like I never left. I've been wondering what sort of changes I would see in the hospitals I go to, the care providers I come in contact with. I was very excited about this birth because the parents were just so willing to ask questions, do some research, do some work and keep their experience and their baby's experience of childbirth as centrally important concepts.
Sometimes people have difficulty getting it, though. Even a family member, when I was talking about my disappointment in the care my clients received, said "but was the baby okay?". Yes, the baby was okay - of course the baby was okay. The doctors want the baby to be okay, I want the baby to be okay, and I guarantee you that the parents want the baby to be okay more than the rest of us put together. If it happened that the baby was really not okay, the parents would be more than willing to change their plan and do what was necessary. But that's not all that matters.
Have you had an experience with a doctor who was overbearing, who tried to scare you into compliance, who steamrollered over your requests because "that's the way we do it"? Were you okay? Were you okay physically? Were you okay emotionally? If the answer was yes to the first but no to the second, did you go back? Many of us have changed specialists because we did not feel emotionally okay with the person. Sometimes we're able to separate these feelings to the extent that we realize the person is probably competent and will do their job well, but we just don't like them. Sometimes we can't separate those feelings: a doctor who makes us feel bad emotionally may very well leave us feeling that we can't trust their clinical judgement, and we just don't feel safe with them.
Feeling safe is critical in birth. Fear and anger flood the body with the kind of stress hormones that can slow labour, create tension in the muscles and make it very difficult for a woman to release - or even want to release - her baby out into the world. Late in labour, fear for her child's safety can make a woman push in ways that may be designed to get the baby out faster, but which compromise her oxygen supply (and thus the baby's), increase her risk of tearing, and affect her ability to welcome her baby with openness and joy, rather than just relief.
On the provider's side, fear and anger make a patient/client suspicious, resistant, and disconnected. Why on earth would you want that? If you can gain compliance, get your patient to do things your way, you may have a good outcome: a physically healthy mother and baby. But what about their emotional health? What about your emotional health? It can't feel good to be having to bully patients into compliance. It can't feel good to have families toss you out of the room and know they're discussing your actions in your absence. On paper, the baby may be okay, the mother may be okay, your actions may be okay. But is that really all that matters?
Subscribe to:
Posts (Atom)
