FIND YOUR VOICE - Conversations at the Hospital

Labor is upon you. When the time finally comes and you’ll have been laboring at home for quite some time, you will “know” when it is the right time to go to the hospital if that is where you have decided to birth your baby. The doula who works with you will be able to assess whether you want to go to the hospital because you are in fear or because you are ready.

Having prepared yourself for your labor I would hope that you want to go because you are ready, not because you are panicking. So what can you expect? There are two major reactions to entering the hospital – a conscious, “rational” one and the unconscious, “emotional” one.

You have consciously prepared yourself for this. You know you are simply using the medical facility but that you’ll bring your “home” with you. In other words, you will essentially continue to labor naturally while there, with the help of your team. You’ll abide by the facility’s rules, that include their need to monitor you for the first twenty minutes or half an hour, and check you both vaginally and otherwise (blood pressure, temperature, etc.). But after you are admitted you will know that you may insist on being able to move around, walk, and even take a shower if you need to, to cope with your contractions.

Unconsciously, your entire being will have a tendency to say “Hey, we are going to the hospital, something is wrong!” After all, that has been your experience in the past . Furthermore, most hospitals will insist that you sit in a wheel chair on your way to Admissions, a practice that can make you feel powerless. It is as if there is something seriously “wrong” with you, that you aren’t even to walk to your room. You are stripped of your comfy home clothes and asked to put on a “hospital” gown, after which you are even visually just like all the other “patients” at the hospital. It becomes hard to avoid the feeling that you are there because there is something “wrong” with you.

Then the word games begin. Following are a few scenarios I have personally witnessed to. But remember the possibilities are infinite. Use your natural instinct and make sure all decisions are made with your informed consent.

Depending on the nursing staff and your care provider, once you enter their territory they will often begin telling you what you should do, how you should do it, when and why. This last may include such rationales as “It is for your own good” and “You do not need to be a hero and take the pain,” and “The health of the baby is the most important thing.” Let me tell you: this is where all the work you have done so far must crystallize if you want to have the kind of birthing experience you have been working towards, dreamed of, and felt entitled to.

I suggest that before you go to the hospital you review your plan with your doula and/or support system. There is never truly a rush to go to the hospital unless it is an emergency[1] -- and if it is, remember that at this point you will become indeed a “patient” and armed with information you will then listen carefully to their suggestion, ask explanation for each procedure and make informed decisions. Here are the seven “Informed Consent” questions to remember:

1. Why is this an emergency? Do we have time to talk or think about this?

2. What are the benefits of doing this?

3. What are the risks?

4. If we do this, what other procedures or treatments we might end up needing as a result?

5. What else can you suggest we try first or instead?

6. What would happen if we waited and hour or two (a day or two, a weeks or two, etc.) before doing it?

7. What would happen if we don’t' do it at all?

Doctors are invaluable when it comes to emergencies, they are good at what they are doing, and they are here to help.

Assuming all is well and before you go to the hospital please review the following. This will take only five minutes, but those few minutes can truly make a world of difference.

Check points:

*Once you arrive at the hospital you will be offered a wheelchair. Resolve to say, “I feel strong enough to walk to the maternity ward on my own two feet and this will help my baby come down even more.” This is the very first breakdown point: once they have convinced you that you must sit in the wheelchair, they have won their first psychological battle[2]

*Once in the triage or in the room of Labor and Delivery.

Be polite, but let the nurse know, right away, that you will be making all the decisions. So for example, if the nurse or any other staff asks you to answer some questions and you are about to manage a wave, tell her, “Just a moment, let me do this contraction and I’ll answer your question[LA2] .” If you are beyond all these words say “Contraction” or raise a hand and go into your contraction meditation and she’ll know you are not ready to talk. Make sure your team takes care of you and doesn’t answer the questions for you (again only if this is not an emergency! I am going to sound like a broken record about this, but this is an important point. We make plans but allow reason and situations to lead.)

As you are getting monitored, you might want to send your partner to talk to the head nurse to request a “natural-birth-friendly” nurse, or you can ask the head nurse yourself. A word about nurses. Nurses are not the enemy: whatever they say to you, their intentions are not malicious. They do and say what they have been used to doing and saying. They have had a long day and dealing with a natural birth is a lot more work for them. They are caught between you and your doctor and they want to please the doctor because they will work with him/her for many years to come, while they will see you only once or twice (if it is a small town) in their entire career. We need to make friends with our nurses. Usually I suggest that you tell them your desire for a natural-birth friendly nurse on your birth plan and deliver that as soon as possible upon arrival at Labor and Delivery. Ask the staff to “Please have e birth plan included as part of my chart.” You may need to use the “head nurse” method only if you feel uncomfortable with the nurse who has welcomed you into the hospital.

After the baby and your contractions have been monitored and if all is well, they will want to check your cervix. Depending on the hospital, you will be checked either by the admitting nurse, an admitting midwife or, in case you have gone to a teaching hospital, you might be checked by a resident. It is very unlikely at this point that your doctor will be at the hospital, but if he/she is there you will obviously be checked by them. A word about residents. For the most part residents are not ignorant students. They have been through training and are supervised by an older resident. That being said, I have had both amazing experiences and terrible ones with residents. Some, too green, inappropriately commented on what should be done, or erroneously measured the levels of waters, used a speculum for a vaginal exam, etc. In their favor, they will have heard the latest research on birth and they might even be more “naturally” inclined then your doctor. So use your intuition , and get in touch with the feeling you get once a young resident presents herself in front of you for a vaginal. It is your body: you choose who touches it!

At this point there are several possible scenarios here are the most common:

* Your waters are intact and you are below 5 cm. You could go home, take a vigorous walk, or take a bath. It would be best to get out of the hospital and MOVE around!

* Your waters have broken but you are less then 5 cm. BEWARE, most hospitals do not like you to go home once your waters have broken, but if your baby is ok, if you feel like you can do it, sign your release and go home. If you stay, be prepared to hear talk of induction. You can choose what to do but be cautious: many times I have heard comments as mild as “If you do not get induced you might risk an infection,” and as strong as “If you don’t get induced your baby might die.” Yes, unfortunately I have heard the last comment, which of course induces guilt, as if one were doing something to jeopardize the very life you are bringing into this world. It is true that once your waters break there are risks of infection, but they usually happen after about 24 hours. So if your waters have recently broken, your baby is doing well, you do not have a temperature and overall you feel fine, there is no reason to stay at the hospital. Do return within the first 24 hours of the breaking of the waters to get checked.

*Finally, you are dilated to 5 cm or more it is time to be admitted and taken to your delivery room.

Now you have been moved to the delivery room.

Settle down and continue with the management of your labor. If all is well you do not need IV fluid, to keep hydrated drink plenty of water. You also do not need to be monitored continuously. You can gently ask to be monitored each hour for about 20 minutes, which is a good compromise with the nurse, since it is her job on the line. But you will need to move around, change position and even take a walk in the corridors to speed dilation. If there is a shower or bath tub available, ask to use it. Settling into the room is far easier after a relaxing, warm shower. You might also want to consider bringing a comfy night gown with you. Be sure that it is one that permits you to access your breasts easily (e.g., is open in the front or has spaghetti straps), and short enough to easily get it out of the way for the pushing stage. Other comforts, such as warm socks and slippers will add to your sense of ease. If your waters have broken you don’t need to be checked often, as this will increase the chances of infection. Let’s talk about vaginal exams during your time in the hospital. Of course you’ll need the initial one, to evaluate where you are in cervical dilation. But once that is done, the suggestion of subsequent exams can be taken with a grain of salt. Bear in mind that following your admission into the hospital all you need to focus on is managing your waves and getting to the point where your body wants to push. Other than that, repeated vaginal checks can work against you. In spite of the many things you will hear about the rate of progression (“You must dilate one cm per hour,” I have even heard “One and one quarter per hour” whatever that means!) each of our bodies reacts differently to labor. Getting checked too often can be discouraging. Best practice would be to set a “checking” schedule that you feel comfortable with -- let’s say every 4 to 5 hours. That translates to simply monitoring your progression. There is no rush in delivering babies, as long as their heart beat remains steady, at between 120 and 180 BPM.

After awhile, here’s what you may hear: “You have been laboring for quite some time and your cervix is still at “x” cm dilated. I’d like you to consider pitocin to “kick start your labor and get this baby out.” At this point, it is essential to establish whether they have suggested natural ways to induce your labor. These natural methods include the breaking of the waters if this has not happened yet; moving around; walking and using a birthing ball. If the baby is not in trouble and his/her fetal heart patterns are normal, you should gently decline the pitocin and ask them to give you more time to kick your labor into gear naturally.

In my last birth I had a nurse who insisted my client needed pitocin to help her during pushing. Her reasoning “Usually during pushing we see three contractions on the screen and with you all I see is one at the time. A little pitocin would really help!” She had not asked the doctor about pitocin she just wanted the pushing to be done a certain way. My client was great and declined each time, but it was getting annoying. So once the nurse suggested pitocin the third time, I looked into my client’s eyes, placed my finger close to one of her ears and said “As I snap my fingers I want you to give yourself a shot of oxitocin, the natural pitocin. One two three SNAP” Sure enough her contraction kicked in and the nurse witnessed the three contraction per screen she wanted. She left the room and said “Keep on pushing with your doula, and if it start to hurt let her give you a natural epidural!”

Consider that the time of the day and the day of the week might be a factor in this rash suggestion for inducement: sometimes (not all the time) your provider wants to manage his/her schedule and time the birth for their convenience. Sometime the nurse is at the end of her shift and wants to get things done. Again, this is not done maliciously, since unfortunately many doctors and nurses believe there is nothing wrong with inducing a patient. Yet research shows that the more medical interventions that occur, the more likely the birth will need additional interventions, and even in some cases turn into a cesarean At times either you or the baby will not respond well to the pitocin. The best practice in this case is to say “I am doing just fine and if the baby is doing well I don’t mind waiting for the natural course of things.”

After a few hours at the hospital and after another check, you might hear the following: “You have been laboring for a while and we don’t see any relative progression. This baby might be too big to fit through your pelvis. You should consider a cesarean.” Here again, you must ask the right questions and be sure to consider all the factors involved. To avoid this early on in your care, try this: after an ultrasound, ask your provider whether he/she thinks that your pelvis is big enough for the passage of your baby. Continue to ask this at each and every ultrasound, through till the very last one. You can then use their own words of reassurance and reiterate that “if the baby’s heart beat is fine you would like to wait. ” Talk to the nurse when you’re alone with her, and to your doula, and ask for their opinion.

I have also heard this one: “You know, if you get an epidural you will relax enough for your cervix to dilate.” It is true that I have seen this happen, yet it is important to realize that what they are saying is that you are tensing up at each contraction so much so that your uterus is working twice as hard. Tell them that you will try to work on relaxing more and would like to reevaluate in a few hours. Now it is time to work on your last fears and embrace the labor dance, determined to relax with each wave. I am 100% against epidurals; often an epidural will relax you, yet if done too early it will stop or slow down your contractions leading to the use of pitocin to re-start the contractions. This begins the medical intervention spiral mentioned previously, in the discussion on epidurals.

“Your baby is in distress. We need to perform a cesarean.” This is serious business and it is not said lightly. Nevertheless, distress occasions certain staff actions. Usually when the monitors pick up fetal distress, the head nurse comes to your room (and at times several people burst into the room) and talks to your nurse about what has been happening. Often in the last stages of labor, the baby moves around and the cord may get pinched somewhere, thus the deceleration of his heart beat. The best thing to do in such circumstances is to move around and even to get up, to see if the baby will move slightly, stabilizing the heartbeat. Once you have an epidural, you often cannot move as freely; you certainly cannot stand up, which is one more reason to ward off the medication, Sometimes, high dosages of pitocin trigger deceleration, so that simply setting your pitocin at a lower level, or shutting it off completely, can get the heart beat to steady. Make sure all those things are done before you even consider a cesarean. Make sure the deceleration is not an isolated instance, but that there has been a pattern in the last twenty minutes and that a change in position has done nothing to improve matters. Again, talk to your nurse and doula in private and ask their opinion. They will be freer to talk to you without the doctor around. At times, doctors after informing you of their decisions for a cesarean will not leave the room. I have found that a great way to have some privacy is to say “OK, I would like to pray right now.” As you’ll see, this statement causes doctors to run out of the room as fast as the speed of light! If this is a true emergency there might not even be time to pray: at that point you must let go and prepare yourself for a different kind of birth, but a birth nevertheless: a c-birth, not a c-section. Do pray or meditate and ask to have a few minutes with your team to center before you change gears.

“If you are not at “x” cm when I call next time, I’d like to start pitocin.” This sounds unreasonable, since neither the baby nor labor can be put on a schedule. Again, if the baby is doing ok, ask to be left alone, to allow your body to progress at its own pace. Once I had a doctor get so mad when a client refused to be induced that she demanded to speak with me. I declined, telling her that the decision was my client’s, not mine, and that she should talk to her directly.

“You have been pushing for awhile and the baby is not coming out. We need to do a c-section.” Every doctor and hospital has set times they will allow you to push before they perform a cesarean. In reality there are no real set times. I have had a client push for as long as five hours: if her baby’s heart beat is fine, you are fine and it is not an emergency, there is no hurry to get the baby out. Once presented with such a statement, angelically ask, “Is the baby’s heart beat ok? Can I hear it? Is he in distress?” If the answer is no, then ask for more time. Close your eyes and talk to your baby. Make sure to tell him that you are ready to embrace him and that this would be a good time to come out.

“I need to do an episiotomy to get this baby out.” More often than not, doctors who routinely do episiotomies will not even ask you, nor inform you that they are going to do this. It is important to have discussed your desires on this matter with them beforehand and that your partner be ready to keep an eye out for you, as you might not be in a position to see what’s going on. If your partner sees the doctor take up the scissors, make sure he/she asks why the provider thinks you need an episiotomy. One thing I often do as a doula is praise my client out loud during the pushing stages with phrases like: “Wow, your perineum is really stretching well, I don’t think you are even going to tear,” or “The baby’s heart beat is so nice and healthy. Aren’t you lucky; you don’t seem to need an episiotomy! But if you do your doctor is right here ready to help you out.” I have seen doctors pick up the scissors a couple of times and then put them down after such comments. I also encourage you to touch your baby’s head as soon as it peeks through the vaginal opening. The more your hands wonder down there, the less likely your doctor will be to give you an episiotomy without your consent.

I could go on and on with many different scenarios, yet the bottom line is this: if you have done your homework and you know what to expect and what questions to ask, it is more likely that you will be respected by all providers. As I have said before make plans but allow yourself to improvise at the moment. Use common sense and your coaching team as a sounding board.

During your entire pregnancy and especially during labor I suggest you find your own voice. Be your own advocate; participate in your care and the decision making throughout this delivery. You will feel much more confident as a person, and later as a mother, and no matter the outcome you will not feel like a victim. In the final analysis doctors will welcome this, for the responsibility of all the choices will not rest on their shoulders alone and less malpractice suits will ensue.

Footnotes

[1] Emergencies include but are not restricted to: Bleeding profusely: filling up a pad an hour. Green, thick fluid coming out when your waters break. Having a temperature during labor especially after your water broke. Vomiting uncontrollably. Although vomiting is normal in an advance stage of labor, continuous vomiting can be helped at the hospital. A constant sharp pain, not ending after a minute. Cord prolapsed, the umbilical cord can prolapsed and may be seen hanging from the vagina. You have not felt the baby move at all in the last two hours. If at anytime you feel something is wrong, call your care provider immediately and discuss your symptoms, or go to the hospital and get checked. Remember if all is well you can return home and continue your labor.

[2] Please, I expect you to use common sense. If you can’t walk, then don’t! I have had clients who have gotten to the hospital while in transition and they of course needed to sit!. The point is that to sit or not to sit should be your decision and not an “abdication” on your part.

All rights reserved No part of this publication can be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopy, recording, or otherwise without the prior written permission of the copyright owner. Joy In Birthing is a registered trademark of Joy In Birthing, Inc. under the United States patent and trademark office.