British nurse in nurses’ station. (Photo credit: Wikipedia)

From a Birth Doula’s Perspective

Doula Faith

“A woman giving birth to a child has pain because her time has come; but when her baby is born she forgets the anguish because of her joy that a child is born into the world.  John 16:21

     I believe there is a growing hostility towards natural birth in hospitals and with many Obstetricians. If you are planning a natural birth in a hospital be prepared to have some and possibly all your plans thwarted.  I have witnessed this occurring enough times to know that even with an approved birth plan, the possibility of actually experiencing a natural birth will be highly unlikely in this restrictive environment.

I’ve been with women during their prenatal exams at the time they present their birth plan to their Obstetrician.   The Obstetrician shows little or no opposition at the time and readily agrees to the plan unless there is an “emergency”.

I recall an example of this that began with my client going to the hospital during

early labor.  She began having steady contractions and when her amniotic membranes broke she decided to go to the hospital right away.  I told her during a previous discussion that the best time to go would be during active labor, but she was still eager to get to the hospital.

I met her at the hospital and found out that her cervical dilation was only 2-3 cm. We knew that she was in the early stage of labor and had prepared what to do during that time.  When we entered the labor room, we were greeted by a very nice nurse who was supportive concerning her birth plan.  She administered the antibiotic that was necessary because of a positive Group B Strep (found in 25% of healthy pregnant women) result during prenatal testing, and at the same time attached my client to the External Fetal Monitor (EFM). We asked how long it would take to administer the antibiotic and she told us it would be for 15 minutes every 6 hours and Fetal monitoring would be every two hours.  My client had requested intermittent monitoring using the hand-held monitor (Doppler) in her birth plan, and asked if the subsequent monitoring could take place using that instrument.  The nurse agreed that it could be done. She even accommodated my client with a birthing ball as indicated in her birth plan.

My client’s plan was to manage the discomfort of labor with hydrotherapy. This hospital proudly boasts of this accommodation in their online Ad. But at 7:00 pm along with the change of nursing staff, my client’s birth plan came to a screeching halt. The mood of the environment switched from supportive to hostile as soon as the nurses on this new shift learned of her plans to labor naturally.  My first clue that the new nursing staff were not on board with my client’s plan came when I informed the staff that we were leaving the room for a while to take a walk. My statement was met with a nurse’s rude reminder to return promptly after one hour.  After the walk, my client’s contractions began to increase with intensity.  When we returned to her room, she was once again placed on the EFM. By this time her partner arrived and he was ready to give his support.   During the monitoring, my client asked the attending nurse, whether or not she was aware of her birth plan.  She said she was not.  So I gave the nurse a copy.  The nurse immediately began to go down the list to tell her why she could not follow her birth plan and argued with her about wanting a natural birth. It was apparent that the nurse had never laid eyes on a mother’s birth plan before. Nor had she witnessed a natural birth.

She asked my client an absurd question, “Why would you want to suffer when it’s not necessary.”  “Don’t you want to have a positive birth?” When my client began to tell her there were risks involved with medical interventions and the use of narcotics, the nurse responded with the statement that she “didn’t know of any”. I proceeded to tell her there were and named a few. She soon left, leaving my client attached longer than necessary to the EFM.  As a Doula I communicate on behalf of my client whenever necessary, so when it seemed apparent that no one was coming back to release her from the monitor, I proceeded to the nurses’ station to make the request.  My request was received as an inconvenience, and was, ignored.   When a nurse finally arrived, she was notably agitated. After my client was detached from the EFM, she began to use the birth ball to help augment labor.  She was doing a great job with this and with her pattern breathing. But unfortunately, she began feeling an unexpected discomfort from an abscess on her spine.  I tried to get the nursing staff to come look at it and asked if anything could be done.  A nurse volunteered to prepare a cold pack to apply to the area, but she never followed through. So subsequently, I took my thermal pack and placed it in the freezer located across from the nurse’s station.  When it became cold enough, I gave it to her partner to apply to the abscess area. Because my client could not stand to sit any longer, she made the decision to get off her bottom.  She began to get on her hands and knees to augment labor. My client decided that she preferred walking again and so her partner and I informed the nurses at the station that we would be back soon.  They again gave a time limit for the walk.  During the walk, my client’s contractions had increased with intensity so upon returning we requested the use of the tub for hydrotherapy (stated in her birth plan). One of the nurses who was seemingly irritated by the request, said “no” because of the possibility of infection.[i]   But another nurse suggested that she call my client’s doctor.  I guess she called, because we were later given permission, but only after again, another cervical examination.  During the exam, the nurse told my client that if she did not dilate at a faster rate she would need Pitocin (artificial hormone that causes unnatural and intense contractions).  Her manner towards my client during the exam was condescending.  She became angry and threatened my client by telling her that if she labored too long she would get an infection because her membranes had already ruptured earlier that day.  I asked, about the 24 hour period normally given for that potential risk but she said it would have to be within 12 hours, even with the nurse’s awareness that my client was receiving antibiotics.   I told the nurses at the station my client’s plans for hydrotherapy.  No one came to assist, so her partner and I filled up the tub and helped her in.  However, the nurse came later to tell her that she would have to get out in a short time for another EFM monitoring.[ii]  After my client got out of the tub for fetal monitoring, the nurse again examined her cervix to see if there was any progress. After the examination the nurse angrily stated that she had made no progress (We later found out that this was not true). While she was attached to the monitor the other nurse who interrogated her as to why she wanted a natural birth showed up to offer pain meds.  She again told her she would need to start Pitocin because she was not making enough progress.

I tried to encourage my client and used comfort techniques to distract her during this time, but without success.

With the discomfort of the abscess (not addressed), the constant monitoring, the hostile attitudes of the nurses, the non-assistance with hydrotherapy and the threat of Pitocin, my client finally lost confidence and surrendered.  Her partner and I tried to encourage her to continue with her plan, but she had had enough. The nurses’ badgering paid off.  She agreed to everything they suggested, including an epidural.  I could not blame my client for any of this.  The nursing staff was so hostile and unsupportive that it proved to be too much for her and for her support team. It was apparent that we were all between a rock and a hard place.  I never witnessed any positive comments from the nursing staff until after the epidural.  After the procedure, the anesthesiologist remarked before departing, “You’re doing a good job.”  That was the only positive remark we heard from anyone.  And it wasn’t given, until my client had surrendered to the staff’s insistence that she give up on the notion of achieving a natural birth.  None of the nurses came back into the room to check on my client, personally, but rather came only to input data (EFM). By the time my client delivered, 20 mu of Pitocin had been administered.  The natural hormone that the body provides in comparison is at the rate of only 9 mu.

With epidurals, it is common for the mother’s heart rate to drop which causes the baby’s heart rate to drop, concurrently. Within an hour of receiving the epidural, my client’s heart rate dropped, and the same nurse who convinced her to have a “positive” birth came racing in along with the anesthesiologist.  They did not speak directly to my client, but rather, communicated only with each other as to what needed to be done.  The nurse indicated that she was unaware that a drop in the heart rate could occur with an epidural. When in actuality, it is a common occurrence.  The anesthesiologist administered a medication to stabilize my client’s heart rate and then left. The nurse then handed my client an oxygen mask. She told her to observe the monitor for the baby’s heart rate, and when it fluctuated to breathe in more oxygen from the mask.  Funny thing, nothing was ever mentioned again about the possibility of infection, even though my client labored with the epidural following the ROM for more than 24 hours.   Even when she was vomiting from the effects of the epidural, no one showed up.   It was left to her partner and I to assist her when she became ill by scurrying around the room in search of a bucket or pan.  Once, while her partner left to take a break, he overheard one of the nurses sarcastically saying, “I guess she didn’t really want a natural birth, after all”.  There were at least six nurses sitting around the nurse’s station who appeared to be socializing. None of them took the time to personally encourage or address my client.

And then it suddenly dawned on me the reason for their relentless pursuit to hook her up to the EFM, administer Pitocin, and seat her with an epidural.  With the monitor in place, the Pitocin drip and epidural managing the pain, their presence was not needed.   They could sit back comfortably at the nurse’s station and remotely monitor the whole event.[iii].

Another thing the nursing staff neglected to do was to monitor my client’s ability to urinate.  The epidural numbs the pelvic region; therefore, there may be the absence of the sensation to urinate. With the epidural medication, a mother may feel little or no sensation from the waist down. Even if she could feel it, she is unable to get up.  Women who have an epidural also receive an additional amount of fluids via the IV to stabilize their blood pressure. Too much fluid can cause swelling in the tissues and result in a full bladder.  No one came to check on whether or not she could empty her bladder and offer catheterization or the bed pan.

This can present problems during the pushing stage of labor.  When my client was ready to push during the second stage of labor, she was having difficulty.  A new nurse (result of staff change) detected this problem and she was able to help my client urinate before continuing to push. The full bladder was blocking the effect.  With an epidural, there is usually prolonged pushing because of the numbness to the pelvic floor.  This may cause a woman to push unnaturally, putting undue pressure on her pelvic organs.  Following the delivery, the obstetrician who was surgically repairing my client’s perineum, made the statement that my client’s urethra had torn.  I didn’t hear how severe it was.

Supporting a woman in natural childbirth means that someone needs to be present to assist her both physically and emotionally.  When a woman is remotely monitored, saddled with Pitocin, an Epidural and other medical paraphernalia, the mother in labor may experience a sense of failure and abandonment.  Labor support persons, especially need to continue their support and attendance at this time. The outcome can be positive with continued support. Also, physically, there are specific methods when applied that can assist with cervical progression and the baby’s optimal transition with positioning into the pelvic region and birth canal. A labor support person can remind the mother of these while laboring with an epidural.

Nurses usually frown upon women arriving at the hospital during early labor because it usually means their prolonged attendance.  That being the case, they prefer to remotely and technologically manage the birth with the use of Pitocin, the EFM and an Epidural.[iv]  Another reason sometimes for the technological approach is ignorance and lack of training with natural birthing techniques.  From the hospital and OB’s perspective, a medically managed birth protects them as it can also provide more data in the event of a law suit.

Positive Note: My client experienced a positive maternal outcome, I believe because of her faith and the fact that her partner and I remained by her side throughout her labor and birth. My client remembered that rotating her hips would help her baby descend into the birth canal.  As the effects of the epidural began dissipation, she began to feel the movement of her baby and assisted his descent by rotating her hips.  Even with an Epidural, if the mother rotates back and forth she may assist her baby to move into a better position for delivery and will obtain maternal confidence by participation in the birthing process.

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• Seven nurse midwives lose physician supervision; expecting moms left looking for birthing care (newsobserver.com)
• Some area women choosing natural childbirth (reporternews.com)
• The Myth of a Safer Hospital Birth for Low-Risk Pregnancies? (zedie.wordpress.com)