September 24, 2009

Birth Plan vs Hospital Protocol

I often encourage my students and doula clients to take some time to figure out how they foresee their birth. This is, of course, with the understanding that nothing – especially birth – can ever truly follow a plan; however, at least one might hash out some preferences and desires toward the manner in which she wishes to birth.

The clients that usually hire me as their labor support doula often have similar requests, requests that are definitely not out of the ordinary when desiring a natural birth: hep lock instead of full-time IV hook up, intermittent monitoring, staying home for as long as possible, having the freedom to move during labor and the freedom to choose the position to birth. Expectant moms should also run these ideas by their care provider to make sure they will be supported with their requests. For the most part, moms come home from this appointment with the care provider feeling assured that their wishes will be heard. These expectant moms enter labor feeling confident and ready to move forward with the birth plan. Until…..they get to the hospital.

OK. I am not knocking hospitals; they definitely play a role in helping people. However, during the last several births I have attended, it has become very clear to me that the hospital’s main purpose may not always be to serve the best interest and comfort of the laboring mom, but to protect itself.

Last Friday night: my client is in labor and, taking into consideration the 4-hour window needed to administer two doses of antibiotics she needs because she is group B strep positive, we decide it is time to head to the hospital. Once admitted, my client was immediately hooked up to the EFM (External Fetal Monitoring) machine. After being on the monitor for over an hour, we asked if she could take the straps off. My client’s doctor had agreed beforehand to allow intermittent monitoring as long as all looked good with baby. However, the hospital’s protocol was full-time EFM. This was a point of frustration for my client since she went in believing she would not be attached to a machine during her whole labor and that she would have some freedom of movement. The nurse explained to us that the doctor was needed to give the order to allow intermittent monitoring. (This being the middle of the night, the doctor is not there.) The nurse was very honest, and pointed out that because everyone works with individual licenses, she had to consider that if something were to happen, she’s the one whose license would be revoked. At one point, she actually said it was illegal not to full to have full-time monitoring. (IT IS NOT ILLEGAL- but a good scare tactic!) After more than an hour and a half on the monitor, the resident briefly agreed to intermittent monitoring. This infuriated the nurse who went to get the charge nurse and the resident who had agreed to it. They came in and told us we had every right to refuse their medical advice, but would need to sign a release form. Not wanting to do this, the husband offered to hold the fetal monitor in place as to avoid his wife being strapped up again.

Along with the plan for intermittent monitoring, the client’s previously approved request to use a hep lock instead of full time IV drip also went by the wayside. As for the antibiotics – the whole reason for arriving a little on the earlier side – we waited almost 2 hours to receive the first dose of antibiotics until the doctor gave the order. The mother had only received one by the time the baby was born.

The point is: what your doctor agrees to will not necessarily be honored unless your doctor is there to sign off on it. Many doctors do not show up until the end to catch the baby. Please note, I recently did a birth with Dr. Bradley (love her!) at St. Lukes/Roosevelt and she was there ALL night – from 5am, when we first arrived, to the following morning. Anyway, I digress. I am now encouraging my students and clients to walk in with a prescription from their care provider supporting their birth plan as long as mom and baby are medically sound.

Doctors and midwives are free agents. They are associated with a particular hospital but do not work for the hospital. Nurses work for the hospital. Their allegiance is to the hospital and (most of them) will strictly follow the hospital protocol. At another birth I attended about a month ago, my client was told that as long as she was going naturally- meaning no pain meds – she could lightly eat during labor. The nurse was VERY unhappy when she saw the laboring woman nibbling on some fruit. We needed to have the doctor tell the nurse she would allow this. Again, the doctor can override some hospital policies.

If you have specific wishes as to how your birth will unfold, you need to get your care provider on board and your partner and/or doula behind your choices so that they can be your advocate. Labor is not the time to be negotiating with the hospital staff. You also need to talk to your care provider and find out when he/she usually arrives at the hospital once you have called them and told them you are on your way. The sad truth is, we are a litigate society. The needs and desires of the laboring mother do not always come first in our medical system. Plan ahead and have open conversations with your care provider about what you can honestly expect at your birth.




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