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A Tale of Two Cities from a Childbirth Educator’s Perspective

January 16th, 2014 by avatar

Today on Science & Sensibility, Laurie Levy, LMP, MA, CD(DONA, PALS), CBE, shares her experiences as a childbirth educator and doula recently relocated to a new state.  Her exposures to a new birth culture and method of doing things has taken her breath away, as she settles in to supporting families in her new home.  Learn more about Laurie’s experiences below.  Have you moved around the country and been surprised at the differences in practice you found?  Why do you think there is this difference?  Please discuss with us in the comments section. – Sharon Muza, Community Manager, Science & Sensibilityimage: http://screnews.com/greer/

hospital-signI moved from Seattle to Northern California this past September.  In Seattle, I was privileged to train and teach with leaders in the birth community for many years. Couple this with the 1998 passage of the WA Every Category of Health Care Provider Statute which compelled insurance agencies in WA state to cover licensed midwives and you can see why I would use the word ‘spoiled’ to describe my experience with birth in Seattle.

At a meeting with some of my new colleagues, I joked that I sound like I am saying, “And one time, at band camp…” when I talk about typical Seattle birth practices.  In the seven hospitals in the metro Seattle area, it was common to see moms moving about the halls with telemetry units.  Occasionally you would even see a woman out of bed and moving with an epidural in place. Vaginal exams were limited after the amniotic sac had ruptured. Babies were not routinely separated from their mothers.  The NICU came to the birth room if needed in most cases.  Mothers were encouraged to hand express colostrum to help a baby with unstable blood sugar. Babies were born directly on to their mother’s chest in some cesarean births. Hospitals competed for patient’s maternity care dollar offering ever improving birth suites with each remodel. Tubs, showers, mood lighting and comfortable spaces for partners to rest were expected in birth spaces. VBACs were encouraged. Mother-baby friendly hospitals were the rule not the exception.

Births in my new community

I recently attended my first series of births near my new home and, while these experiences are only a thumbnail of a much bigger picture, I found the differences in environment to be very stark indeed.  In fact, few of the practices I saw lined up with Lamaze International’s Six Healthy Birth Practices.  I am not a Pollyanna. I know that Archie Cochrane awarded obstetrics the “wooden spoon” in 1979 for being the least evidence based medical speciality.  I have talked with nurses from other states who tell stories about mothers being confined to bed after their water breaks for fear of a cord injury or other such superstitious practices. Still I was surprised at what I saw and have been thinking about the challenges that will face me here as I start teaching childbirth education in my new home.

My intent is not to malign any of the practitioners who I met.  In fact, I found that virtually every staff member that I observed wanted the best for their clients and were trying to make the best of a less-than-ideal situation. To protect confidentiality, I have combined information from several births and changed insignificant details, though I have not fictionalized any of the practices.

Healthy Birth Practice 1: Let labor begin on its own & Healthy Birth Practice 4: Avoid interventions that are not medically necessary

My client had some complications and I believe most practitioners would agree that the benefits of an induction outweighed the potential drawbacks. While I have no issue with that, I question why a provider would offer to break a mother’s amniotic sac when she was only 3cm and clearly not in labor.  There was no discussion of possible complications, no discussion that this practice sometimes slows labor or does nothing rather than speeds it up (Smith, et al 2013.)  AROM did nothing to progress my client’s labor and after 9 hours and 5 vaginal exams, she spiked a fever. This led to antibiotics, Tylenol and a spiral of other outcomes that I will address later.

Healthy Birth Practice 2: Walk, move around and change positions throughout labor

My client wanted to move around in labor but was being continuously monitored.  Her window-less room measured 10’ by 8’. She and her family spent a full 24 hours in this room. No one offered a telemetry unit which would allow her greater mobility and when she asked, was told that the L&D floor had one telemetry unit, but the cord to connect the device to the EFM machine was missing. My client requested to shower, and the only shower on the floor was down the hall, none of the rooms had their own.  Showers were also not allowed when Pitocin was being used.

Healthy Birth Practice 3: Bring a loved one, friend or doula for continuous support

I have to say on this point the facility did pretty well. Like most hospitals, they had a practice of only allowing one support person in the room when an epidural is being administered and during cesarean birth.  My client had her epidural reinserted repeatedly.  I was only asked to leave the room once and was allowed into the surgery after much pleading and crying by the mom.

Healthy Birth Practice 5: Avoid giving birth on your back and follow your body’s urges to push

My client was asked to do a “pushing trial” to see if the physician could reduce the anterior lip that seemed to be holding up progress.  She pushed on her back as that was the only position her provider was comfortable with and, as you will see below, she was unable to support herself in other positions.

After 24 hours, we did end up in a room that had its own toilet.  Few other rooms did.  None of the rooms had a tub and clients were not allowed to bring one in.  The standard was communal bathrooms for women in labor, one shower for the entire unit and no refrigerators anywhere to store patient food for use during labor.

It was my client’s intention to hold off on pain medications until after six centimeters (active labor.)  We were creative but a 24 inch movement radius, lack of access to a tub or shower and continuous pitocin led to an epidural earlier than planned. There were some complications with the block and it needed to be replaced several times, and the final medication level was so significant that the mother had absolutely no ability to move her legs on her own at at all.

Healthy Birth Practice 6: Keep mother and baby together – It’s best for mother, baby and breastfeeding

I already gave away the ending – this mother gave birth by cesarean section.  The operating suite was a fairly good size and I was allowed in the operating room as a doula.  Baby was born immediately yelling and pinking up.  Mom got to see her newborn over the blue screen but baby was immediately brought to the warmer.  I heard the pediatrician say “This baby looks so great I am going to leave!” Even with all of that, routine procedure was for baby to be recovered in a separate room.  Staff would give baby all of her injections, weigh and measure her and bathe the baby before returning the baby to mom’s recovery room.  Standard procedure.  Baby was away from her for a full hour before they had any more than a cursory hello.

After the birth, my client asked that I let her family know that she and the baby were healthy.  The extended family seemed very calm when I told them the good news.  They were unconcerned because they had already seen the baby.  I turned around to see into the nursery where one of the grandmothers was cuddling the baby in a rocking chair.  The extended family was holding the baby before the mother.

Thoughts for the future

Upon leaving, the attending physician told my client, “There is no reason for you not to have a vaginal birth next time.  Just not here.”  Apparently, there has been no change in policy about VBACs even with the recent change to the ACOG guidelines (ACOG, 2010).  This hospital has a VBAC ban.

I am not trying to demonize the health care providers or nurses.  I don’t believe that anyone enters maternity work with the idea of oppressing women.  I do believe they were doing the best they could within this system.  This hospital does have plans to address the facility issues but those will take quite some time and hundreds more women will labor and birth before those changes are made.  Probably more important, I wonder how long it will take for a cultural shift even with floor plan improvements.

Jerome Groopman, M.D. in his book How Doctors Think discusses at length how medical providers – and really all of us – make the same errors of logic and repeat them over and over.  So, while I am all for cheerleading and encouraging parents to advocate for themselves, ask for change in the system, understand the evidence for various practices, I also know that most people have a hard time hanging onto their personal power in a medical setting having been socialized to defer (see another Jerome Groopman book, Your Medical Mind) to their provider.

I am much more interested in preparing parents with real world expectations about what practices actually take place in their local birth community. The childbirth classes that I teach here will by necessity be different from what I taught in Seattle. Best practices are just that, but navigating the realities of what is and still having a positive birth experience vary from locale to locale.

To truly prepare parents, it is imperative that I include curriculum about what really makes up informed consent.  Research may tell us one thing, but choice of provider, provider’s preferences and the personal values of the birthing woman all figure into what makes up this slippery thing called “informed consent.” I have found that many expecting parents have never made a health care decision together and have never discussed their values around health care.  Exploring values and how they relate to medical decision making must also be included in childbirth classes to adequately prepare parents. This self-knowledge is not limited to the labor as it will serve parents well as together they navigate future medical decisions for their child.

And finally, parents need concrete tools and classroom practice talking to providers about their wants and desires.  ‘What the brain fires it wires,’ neuroscience tells us. By tools, I mean a concrete list of conversation starters. For example, “I hear what you are suggesting.  I would like to tell you a bit more about where we are coming from.  We would like delayed cord cutting because we value an unrushed separation)” (James, et al, 2012). The role play speaking values and truth in a safe classroom environment can help make parents more likely to actually do this during the stress of prenatal visits and labor ( Arrien, 1993).

I am so grateful that I get to work as both a doula and a childbirth educator.  I gain so much information from each role that helps improve my work when I am wearing the other hat. I know that not every childbirth educator can attend births but I would encourage educators who can, to do so, and also to work in concert with doulas and other childbirth professionals to find out what is really happening in their area.  Additionally, surveying past students to find out if our presented curriculum addressed the real needs of parents as they progressed through labor can help educators to adapt what we teach to meet those needs.

I am confident that the families that I work with both as a childbirth educator and a doula will benefit from my experiences of what is possible and together we can encourage change to practices that are more in line with best practices in obstetrical care.

References

Arrien, A. (1993). The four-fold way: walking the paths of the warrior, teacher, healer, and visionary. New York, NY: Harper.

James, K., Levy, L. (2012, October). Doubters, believers and choices, oh my. Concurrent session presented at the Lamaze International Annual Conference, Nashville, TN.

Smyth RMD, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub4.

Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63.

About Laurie Levy

Laurie LevyLaurie Levy, LMP, MA, CD(DONA), CD(PALS), CBE is a licensed massage practitioner, birth doula and childbirth educator, human anatomy and physiology instructor, and mother of three rambunctious boys.  Laurie has presented at the 2011 Lamaze InternationalConference and hopes to sit for the LCCE exam in 2014.  She can be reached through her website, laurielevy.net

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, informed Consent, Maternity Care , , , , ,

  1. January 16th, 2014 at 14:24 | #1

    Whoa. Laurie’s review makes me very glad I live in a different city in the same state! And I am stunned as I thought her city would be far more progressive given some of its radical advocacy history!

    So far births I have attended in hospitals in the city I moved to from Seattle a year ago (not sure if we’re allowed to say where we live but since Laurie didn’t, I won’t) have been surprisingly mindful of informed consent, birth plans and holding off on intervention as long as possible (even in one particularly hairy situation where the OB truly allowed the mother to make her own decision re surgery without undue pressure despite FHTs dipping constantly to 70 with slow recovery in a mom 80%, 7 cm and swelling and -2. This 10 minute pause was critical to the mother feeling positive about her birth and feeling like she was a respected decision-maker). I was invited to stay in the room during epidural administration into the OR with the partner, although I am unsure if this was standard.

    I concur the birth suites are a far cry from even the least labor friendly in Seattle – at one major hospital here there are no tubs or showers in labor suites. At another no tubs, just showers. At a third, impossibly small tubs and not showers. No hospital allows an outside tubs. The idea of shared bathrooms blows my mind!

    None of the providers at three births in these three hospitals (I’d guess about 30 in all) had ever heard of or seen a TENS Unit although one anesthesiologist was quite enamored of mine! None felt water immersion was particularly helpful for coping. One nurse (who was a midwife long long ago) was so thrilled to see a rebozo, she had me show her some moves. Three births is in no way enough to paint an accurate picture of a birthing community, so I am eager to see how things unfold. But man, I’ll be carrying a copy of Laurie’s missive with me and taking notes and thanking my lucky stars for my clients if they don’t face what Laurie’s client faced.

  2. avatar
    Sara Temba
    January 16th, 2014 at 15:01 | #2

    A friend moved to Southern California to be near family but, being a maternity nurse and having to work full time, she ended up moving back to Seattle. The practices at her hospital (and all the others in the area)made her feel she would lose her soul. Immediate separation of mother and baby after all births, completely non-evidence based care, everyone getting continuous monitoring, pitocin, epidurals. The stories she tells are shocking. In the magazine put out by our professional organization there are cover stories about recovering moms and babies together after C/Sections as if this is a new, exciting trend. Many, many hospitals do not. The idea of the extended family holding the baby before the mom?? We don’t even let them in the room for the first hour so that the baby stays on the mom, uninterrupted. Seattle really is an island unto itself when it comes to maternity care.

  3. January 16th, 2014 at 16:01 | #3

    Uh oh ~ look who’s rocking the boat! Birth Doulas in the Puget Sound area are now thanking their lucky stars, and parents in Northern California are lucky to have someone who knows better in their midst. Laurie, you are brave to be a drop that may become a ripple. I hope that you create a childbirth education position soon to help enlighten families and create the demand/outcry that starts hospitals competing for their business. Mothers need to know and babies deserve their (proven) best start! <3

  4. avatar
    Kim James
    January 17th, 2014 at 07:47 | #4

    Thanks for this powerful illustration of birth in two cities, Laurie.

    Awareness cures. Through this article, you’ve helped many of us see the possibility of improvement when consumers are aware “of what could be” and where their providers’ and hospitals’ fall on the standards of care spectrum.

    When consumers (and care providers) are aware there is a spectrum, the spectrum is broad and that they are no where near the top range of care, we are more likely to achieve change.

    Thanks again!

  5. January 17th, 2014 at 07:57 | #5

    I don’t think that this article is so much about a competition or a statement about superiority. Laurie’s experiences touch me on a different level. I am saddened that there is not a) equal care and b ) practice based on evidence for all women no matter where they live. A woman’s birth outcome can vary, simply based on her geographic location. And a childbirth educator faces even more challenges when she is located where every birth must proceed through this type of unfair challenge.

  6. January 17th, 2014 at 12:08 | #6

    Me too Sharon. Saddened and shocked. Shocked at my own assumption that at least on the west coast we are progressed as a unit. But then I think of the leadership here — the Sharons, Lauries, Kims, Pennys, Annies and so many more here who have lead a movement here to make this region a leader in the movement. And it IS a movement. An ongoing movement. I am glad Laurie’s city has her, frankly.

  7. avatar
    Marilyn Curl
    January 18th, 2014 at 07:24 | #7

    For the past decade I have worked as an interim L&D nurse in several states and am now employed as interim manager of an OB unit. Laurie’s story is spot on!

  8. January 20th, 2014 at 11:34 | #8

    thanks for this interesting read. good coverage.

  9. avatar
    Pamela Augustine
    January 31st, 2014 at 17:47 | #9

    We are indeed fortunate to have Laurie join our birth community. We have 3 major hospitals, 1 detached birth center and many talented home birth midwives. I am a birth doula and childbirth educator at the birth center. I have attended births at all local facilities and what she describes has been my experience as well. The birth culture that resides in the hospital requires parents to be well educated and vigilante about routine procedures practiced. Many parents believe that 6-8 hours of education adequately prepares them for this journey. I will be eternally grateful for the 24 hours of instruction I received. Every moment of discussion with my peers and skilled educator made it possible for me to have an unmedicated natural birth at a very conservative hospital. Right on sister!

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