Tangled in the Safety Net

One of the blogs most recently added to my blogroll is “Birth Sense,” previously, “The Midwife Next Door,” and I’m glad I’ve found it. In a recent post, she details a birth story, illustrating that the “safety net” of a hospital may not always function like it should.

In most hospitals today, you will see a central monitoring station with nurses clustered around it, eyes fixated on the monitor screen.  Rather than spending this time in one-to-one assessment of their patient, observing the whole picture of how things are going, they focus on one element of the labor–the fetal heart rate.  Where is the physician?  At the office, or elsewhere, while the nurse is expected to monitor and identify problems with the labor and notify the physician if problems arise.

This is one common misunderstanding regarding home vs. hospital birth.  Many women feel safer in the hospital because they have emergency services immediately available.  But if you have an emergency and your physician is not at your bedside, who is going to perform emergency surgery?  The nurse? The anesthesiologist?  No, you will have to wait until your physician is summoned and arrives at the hospital, assesses you, and makes the decision to perform a c-section…..

I paged the chief again.  I called my supervisor again.  No other doctors were  on the floor, or I would have begged one of them to help.  No one was answering my calls.  I finally called Brianna’s physician again and told her that I had notified the OB chief  and the nursing supervisor that she was refusing to come in.  Very angry now, she hung up on me.  A few minutes later she walked into Brianna’s labor room.  I still had not heard back from the OB chief, and the nursing supervisor was also trying to reach him….

Click here to read the rest of the story.

Breastfeeding and PCOS

Wow, what a full post! You may or may not be familiar with “Hot Belly Mama,” but she recently gave birth to her first child under less-than-ideal circumstances (what that means, exactly, she has not said, just that her birth experience was not what she wished and hoped for), and in this post writes about her experiences with breastfeeding in the hospital.

She has PCOS, which, apparently, causes delays in breastfeeding and low milk supply in up to 30% of affected women. None of the medical staff at the hospital had any information for her on that, and she didn’t realize at the time that PCOS could affect her breastfeeding. The nurses couldn’t help; the lactation consultants couldn’t help; and, well, let’s just say that she began referring to her child’s pediatrician as “the evil Dr. Jones” for her much worse than lack of helpfulness — did nothing but promote formula (while saying she was 100% pro-breastfeeding). Also, the doctor refused to let the baby leave the hospital until she gained weight, without regard for the stress the hospital was causing the mother, without any apparent knowledge of how PCOS might affect breastfeeding and milk supply, without being able to help, without diagnosing the baby’s tongue tie and upper lip tie (which were also affecting her nursing ability [for a long post on tongue tie, click here]), and without any apparent regard for the parents’ already working with lactation consultants and being willing to go to the doctor every day until the baby gained weight (in other words, it’s not like they were neglectful parents, but were doing everything possible).

But the angel of the story was the La Leche League leader who did what none of the professionals apparently could do. Although she had no knowledge of PCOS herself, she started searching the internet for advice and information, and was able to help this new mother, when others could not or would not. When doctors and nurses get irritated by people who are willing to listen to those who are not doctors and nurses, or those whom they consider to be quacks, perhaps they need to be reminded of stories like this, and how a “regular person” was able to solve a problem that the others could not. This is not to say that the nurses and lactation consultants didn’t try — I’m sure they did. But they didn’t have the knowledge base to help, and although this woman was in the hospital for three days, the lactation consultants didn’t come up with the information to help her in that time. But a LLL leader did. Sometimes, it’s not education but dedication that matters.

Birth wars

This post is a must-read for everyone. I won’t comment on it, so as not to detract from it, nor to take any extra time — except to say, it’s from Australia, so aside from a few things that pertain strictly to that country, it could be written about America. Just go read it. Here’s a teaser:

YOU’RE in the dentist’s chair with a painful tooth, feeling fragile.

“That tooth has to come out,” says the dentist.

“I’ll give you an anaesthetic and extract it.”

You’re surprised – you had hoped the tooth would be all right – but you nod and say something like “Ungh-hnghm” through a mouthful of cotton wool and dentist fingers. After all, he’s the expert.

The dentist turns to prepare the needle, when a dental technician leans over and whispers in your ear: “You know you don’t have to do what he says.

“He doesn’t know what he’s talking about. What about root canal? Or homoeopathic remedies? And anyway, you don’t need an anaesthetic.

“There’s a dentist next door who does acupuncture and hypnosis for pain relief. It’s much safer. Oh, and did you know fluoride is toxic?”

The dentist snaps at her to stop: “Ignore her – she’s pushing her own agenda.”

Tense, stressed and utterly confused, you lie back, open your mouth and look up at two medicos glaring at one another.

Who is in charge here? What’s the real truth? And why didn’t anyone tell you there was some sort of power struggle going on?

Of course, this doesn’t happen in dental surgeries. Open hostility between clinicians would be madness, serving only to baffle patients and undermine the whole purpose of creating healthy smiles.

But this is exactly what happens in maternity care, every day, in birth centres, hospitals and homes. Hostility, suspicion, mistrust, abuse and vitriol abound in relationships between obstetricians and midwives, clinicians, academics and activists.

h/t to Sidney Midwife for the link

Not “Hospital Property” Gowns

A friend sent me this link, and it intrigued me, and I wanted to get other people’s opinions on it, as well as get it to a broader audience: More than Maternity Hospital Gowns. Go see the fabric choices, as well as read the descriptions. The website looks very preliminary, with the likelihood of them adding other items for sale in the near future.

While the gowns may seem expensive, it is worth noting that they are hand-made. Although at first glance it appeared that the gowns would not allow for easy nursing (few dresses do allow for that, I’ve noticed), the description says that the shoulders unsnap, which then does allow the babies to nurse. There are snaps up the back, so that if you need access to your back (for instance, for an epidural), the dress/gown will accommodate that. It’s certainly better than those horrid hospital-issue gowns (particularly the ones that proclaim “Property of X County Hospital” like one might see in jails). These gowns are cut with an empire waist to allow plenty of room for the pregnant belly; plus the fabric selections are quite nice — certainly no comparison to hospital johnnies.

You know the saying, “The clothes make the man”? Have you ever noticed that you act differently, based on how you’re dressed? I do. I dress one way to go to a wedding and another way to go to the store; and I carry and comport myself a bit differently, based on not just the occasion, but also how I’m dressed. There’s a reason why uniforms are issued for soldiers and prisoners — to make them lose their individuality and conform to the standard set by authority (it works for the military; not so sure about the criminals). Robbie Davis-Floyd talks about this concept in her paper, “The Rituals of American Hospital Birth.”

Of course, you don’t have to wear a gown of any sort in the hospital — you can wear nothing at all if you want (although some people, and not just the laboring moms,  may be uncomfortable with that), or wear regular clothes. But if you do end up choosing or needing an intervention that requires you to change your clothes, you may end up stuck with an ugly johnny proclaiming that you are now the hospital’s property. A dress or gown of some sort allows for birth more easily than, say, blue jeans would. Although wearing some form of bottoms would perhaps keep vaginal exams to a minimum — some women have described their hospital labors in terms of having no privacy, with basically anyone in the building allowed to come and stick their hand in their vagina to perform a cervical check. Exaggerated, of course, but that’s the way they felt. When access is physically restricted, it becomes easier for the mom to say, “no,” or at least to be much more picky about who gets to do vaginal exams. When a nurse can’t just open her legs but must physically undress her, that’s a bit more of a barrier (and I’ve heard of such pushy nurses or doctors, although those are hopefully rare). So, that’s a downside of any gown — although I suppose you could pair it with matching leggings (those are back in style again, aren’t they?) and then, problem solved. Of course, you’ll have to take them off eventually, which might be irritating and a hassle in late labor.

So, what do you think?

Just watch out

It’s always a good reminder for everyone, because you never know when you, your child, or someone else you love may end up in a hospital. (Of course, if you’re planning on giving birth in a hospital, then you do have advance warning for this.) Hospitals have a lot of things in them that aren’t in most other places — doctors, nurses, orderlies, drugs, patients, germs, equipment — whether for good or for bad, these things mix and mingle. Humans are prone to error; drugs may have different effects on different people; equipment can only do what it’s told to do (and it may be told something wrong by accident); and germs… well, germs are germs, and they are more likely to be super-bugs in hospitals, and since there are more people — some who are very sick — in a hospital than in many other places, you may be exposed to more potential of illness.

There are steps that some hospitals are taking now to reduce human errors — things like bar-codes and scanners to make sure the right drugs are delivered to the right patients — but not all hospitals have them, and they cannot work completely perfectly 100% of the time. Just impossible.

So watch out. Be alert. In light of the latest news on the… drug overdose… drug interaction — whatever it finally is proven to be — that killed Michael Jackson, it is imperative that you make sure that yourself or those you love are not overdosed, nor have any dangerous interactions. You can’t really do this since you haven’t been to pharmacy school to know how the drugs all act and interact; you don’t know how they’re typically dosed; you don’t know what an overdose or contraindication can be. But you can still be vigilant and be proactive. First, you can make sure that you understand what each drug is supposed to do and how it is supposed to be given. This is as simple as asking the nurse what the name of the drug is, what it’s being given for, and double-checking the dosage. You may be a pain in the butt, but you might be a live pain in the butt! Ideally, s/he should do this first, so you don’t even have to ask; but if not, remember that it may be a cliche, but it’s still accurate — “An ounce of prevention is worth a pound of cure.” If you’re taking medication on a long-term basis, you need to understand that medication better than most doctors and at least as well as any pharmacist.

My sister’s nephew was rendered permanently disabled, practically a vegetative state (although you can tell he’s still “in there”… sort of), due to a medication error. He became very dehydrated, and instead of being given a glucose solution to rehydrate him, he was given a saline solution which dried him out even further. [Updated to include Pinky’s comment, that most saline solution given in the hospital by IV would be “normal saline” which would not do this. Don’t want anybody freaking out about normal saline (NS) in an IV.] He was a bright and active 10 month-old, saying words, understanding everything, even walking; and he became basically a vegetable. When I was there, if he was put in his room while others were in the house, he would register his disappointment(? anger? frustration?) at not being in the middle of the action. So he was obviously aware of his surroundings, but he couldn’t say anything more than moans and other incoherent forms of pre-speech — like what a 6-week-old baby might say. Because of a medication screw-up.

Rare, yes; but it can be made rarer. That will take more vigilance on the part of everyone (doctors, pharmacists, nurses, and patients [or parents]) because we’re all human, and we all make errors. So watch out to make sure you don’t end up on the wrong side of the error. Just be careful.

Update:

I just read this story about two women in the same hospital within hours of each other being mistakenly given Prostin (which induces labor, sometimes given after fetal demise to complete a miscarriage) instead of Progesterone (intended to prolong the pregnancy). One woman lost her pre-viable twins; the other woman’s baby suffered brain damage and — 11 months later — is hospitalized with health problems. This could have been so easily avoided — the first way that pops into my head is for the nurses administering the drugs to look at the patients’ charts to see why they’re in the hospital. Both were admitted for bed-rest to prolong their pregnancies, not for complications of a miscarriage! Although it’s possible that the nurses mistakenly grabbed the wrong drug thinking they had the right one, you’ve gotta double-check yourself on that! Oh, so sad!!

Not that we didn’t know this already…

…but reducing the rate of Pitocin reduced the rate of emergency C-sections and vacuum or forceps deliveries. Click here to read the whole article. One thing that was (negatively) intriguing to me, is that the hospital’s Pitocin rate prior to the change was 93.3% — almost every woman planning a vaginal birth (at least, I assume the numbers would exclude planned C-sections; and didn’t include postpartum Pitocin use) got Pitocin either to augment or induce her labor. Even after the protocol change, over 3/4 of the women still received Pitocin.

h/t to Empowering Birth for the link

Also, in light of the whole “Pit to Distress” conversation, the above article had a link to a AJOG paper, which it cited as evidence for suggesting that pitocin not be increased more frequently than every 30 minutes (although many hospitals currently increase it every 20 minutes). The paper had the following abstract:

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications “bearing a heightened risk of harm,” which may “require special safeguards to reduce the risk of error.” Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

Patient Advocates

Over the course of the past few months, I’ve read numerous things from various sources — emails, L&D nurse blogs, links to nurse things — that touch on the topic of “being an advocate for the patient.” One nurse forum had the line, “Be nice to your nurse — we keep your doctor from killing you,” or something similar. Humorous, but probably with a nugget of truth.

One of the links was to a nurse’s forum and a discussion on how much Pitocin the nurse should give the patient — the original question was from a nurse who was given orders by a doctor to give Pitocin in a large dose to start with, and/or increasing it by too large an increment or too close together — whatever it was, it was so egregious that several nurses expressed shock that the doctor would even order it, and strongly recommended that she document everything (to cover her own butt), and other nurses said they would usually say, “Yes, doctor,” and then ignore the order if it was something they were uncomfortable with. (Need I elaborate on how distressed I was to read this thread?)

Some nurses might get a little edgy or “territorial” over things like the woman having a doula, saying things like, “She doesn’t need a doula to advocate for her — that’s part of my job description!” To which I say, that’s pretty good proof, then, that the average woman does need a doula in a hospital. My line of reasoning is this — why do laboring women (and other people in the hospital) need patient advocates in the first place? It’s because sometimes their wishes are not honored or respected, or perhaps the doctor screws up (either due to being only human, or because he’s acting rashly, trying to speed up a birth and not caring if the woman has a C-section or not due to fetal distress from too much Pit), or some other reason. The nurses can be a buffer between the doctor and the patient. So can a doula. While some nurses may be able to fulfill that role, other nurses can’t, won’t, or don’t, and the pregnant woman will have no idea which kind of nurse she will be assigned to prior to going into labor. Having a doula can be a safety net in this area.

If the hospital system were “ideal,” nobody would need anyone else as an advocate, because the doctors would do just what they were supposed to do, and would explain things like they ought, and practice evidence-based medicine, and have a good bed-side manner and all that jazz. But sometimes they don’t; and that’s where a patient advocate comes in. But what if the nurse assigned to the patient isn’t a good advocate either? Where does that leave the patient? The very reason that the nurse needs to advocate for her patient is the very reason why she should have a doula. A doula can’t countermand idiotic medical orders, but she can suggest things that can minimize risk — such as, if the contractions are already in a good pattern, could the pitocin be turned down or off, to see if labor continues? can we try X before we have to do Y? is there any reason why she can’t go to the bathroom herself, rather than get a catheter? — that sort of thing. Being familiar with various medical and labor/birth terms, a doula can also explain things to a laboring woman or her family if the doctor or nurse can’t or won’t.

Patient advocacy is just one aspect of what a doula can do — even if you have a great doctor and/or nurse so don’t need a patient advocate as such, you may still want a doula to help you through labor, because very few medical staff will have the time, desire, or ability to really be with you during labor the way a doula can.