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| 07/20/2005 9:24 AM |
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I have a client who is 37w3d. She is planning a midwife-attended birth center birth. She and her husband are cash pay- no insurance/no Medicaid. She very much wants an unmedicated birth.
In the last month or so, her blood pressure has been iffy. Sometimes in the normal range(112/78) and most of the time around 135/85. She is taking increased magnesium on the advice of her midwife, is not on bedrest but is on "light duty"- mainly hanging out at home, not exerting herself much. She is bearing the Brewer diet in mind and keeping her protein intake up. She is not restricting salt and is staying well-hydrated.
She is VERY motivated for a natural-out of hospital birth and is extremely conscientious about staying compliant with all her midwife's suggestions (above).
At her appointment Monday, when first her BP was taken, it was not good- 150/98. After fifteen minutes resting in the exam room with the lights dimmed, being calm (after having had a near-miss car accident on the highway en route to the appointment) it was back down to something like 142/89 or something. Lower but still not great. When she takes it at home, it is pretty stable in the 130's/high 70's to low 80's.
So although it came down, her midwife requested that she do the 24 hour urine collection to check for protein. Hopefully we will get results of that tomorrow. She has no pitting edema, no visual disturbances, no headache.
Okay, so here is my question. As her doula, it is my job to provide emotional and physical comfort and informational support. She is very well-informed, has read a lot, etc... but her husband has not and is not very supportive (which is why he suggested she hire me- he wishes she would just to go to the hospital, have an epidural, and they could play cards or watch tv until the baby was born... that kind of thing..!) And once she is in labor and not in "thinking mode", she may be counting on me to give her information that she "knows" but isn't thinking of at the moment.
In the event that her midwife (who admits that she is very conservative with regard to "risking out" folks from BC/homebirth) wants her to transfer during labor, and we are in a hospital instead of the out-of-hospital birth my client wants, I am not sure how to handle my role. I don't want to support or encourage her in going against needed procedures even if the procedures are not what she wants. On the other hand, because procedures are so often suggested/pushed when they are NOT needed, I am not sure how to know what is or is not needed. I have never worked with a mom who could turn out to be anything besides low-risk.
What does evidence-based care in a hospital look like in the case of a client with high blood pressure, should my client's BP risk her out of her planned birthplace/provider? What "routine"
procedures which are ordinarily worth avoiding (like CEFM vs IEFM or just intermittent doppler, for example? IV vs saline lock? etc.) might be worth having in this case?
And if my client does not want something that her caregiver (who she would likely never have met before and with whom she wouldn't have a relationship, if it were a transfer during labor) is
recommending, and she is asking me for information about her options... or wanting to refuse it even if it is being recommended to her, and I have no idea of the risks/benefits of it based on her special case, what on earth do I do?! Interventions are SO badly overused in our area (our area hospitals have a 90+% epidural rate, and c/s rates of up to 36+%... it is not a good climate for normal birth even in uncomplicated pregnancies) that I do not feel confident in my ability to help my client achieve as normal and noninterventive a birth as possible if she goes in as "high risk". And I don't know which points are not worth sticking her neck out for, if they might have more benefit in her case than usual. I just usually work with low-risk women... hmmm.
Gosh, I hope her BP stays reasonable and that she is not spilling protein and this is all a moot point and worrying over nothing... but I could use some suggestions, in order to be prepared if it DOES turn into something....
Thanks in advance for any best practice and evidence based information regarding this situation!
Delilah
By: delilahdr1 |
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| 07/20/2005 1:37 PM |
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This is not as difficult as you think. Your role is to help her make informed choices and support her in whatever choices she makes but not to advise her yourself. To begin with, go to Making informed decisions and download a copy for your client. Among other useful information, it contains questions your client should ask about proposed interventions or tests. Another question I would add to the list is: "How urgent is it that we begin treatment?" The answers will enable her to make an informed choice. Similarly, ICEA sells business sized cards with "Key Questions about Your Care" originally developed by Penny Simkin. You might want to buy some to hand out. If you are interested, go to http://icea.org/B&pennyp.htm and scroll down.
You might also suggest to her that once she has her questions answered, she ask for time alone to talk things over with her husband--unless, of course, the situation is urgent, which it almost never is. This will give them--well, her, really--time to make up their minds without feeling pressured.
Since there is a fair probability that she will end up risking out of the birth center before or during labor, I suggest she tell her midwife that her goal is to have no more interventions than she needs given her individual condition. That being so, how can she maximize her chances of having an ob whose philosophy and practices are in line with the birth center's?
As for you, it sounds like even if she follows through on asking questions and strategizing with her midwife, there is still a fair probability that your client will end up having interventions that you may not think were necessary. This means the birth could be emotionally tough on you regardless of whether it is on her. I recommend having someone safe you can vent to and who will commiserate with you standing by for you after the birth.
-- Henci By: Henci Goer |
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| 07/21/2005 10:41 AM |
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Thank you, Henci, for your encouragement and understanding.
You are right, I do get invested in my clients' birth experiences and when it isn't satisfactory to them (or when they are okay with it but I know how it could have been so much better "if only" and they don't even know how it could have been so I have to just let it go and be happy that they are happy, even if I wish...) it does take a toll on me sometimes. It's still worth it to me, though- I think one of the main reasons clients hire me is because they perceive that I truly care about them having as close to what they want as possible and my honoring that having desires for one's birth is reasonable and does not mean they are "ungrateful" or greedy to want more than just the bare minimum of a healthy mother and a healthy baby...
I have printed out the WHO recommendations for diagnosing/ managing/ treating hypertensive disorders of pregnancy and the Maternity Wise chapter 15 regarding the same, and read them thoroughly. This made me feel somewhat better, about my ability to help my client understand what options are being presented (or, more likely, what her options are even if only one course of action is being presented). I emailed her and gave her some ideas of things she could choose and gave specific examples of how to apply the informed consent questions. (IC is one of the things I hammer hardest in my CBE classes.) For example, if she sees the midwife's backup OB, who the midwife feels is one of the most liberal in practice of area OB's (this is a VERY conservative/defensive active management area), and even that OB recommends induction, she still has options. Here is a snippet of the email I sent my client:
Well, I will just throw this out there. You could go ahead and consult with Dr. D, and hopefully she will say that M (midwife) can continue monitoring you as long as you stay "in consultation"... which would be a very good thing for your chances of the birth you want, with M at the birth center.
BUT, if it should come to a point where even Dr. D says you need to induce and risk out of the birth center, you could choose to go to someone else rather than her for your actual birth. Partially this
would be getting a second opinion (well third, really- but second OB opinion) but mainly it would be hopefully getting a care provider you like better since you have already stated that you do not care for Dr. D...
And also, just to throw this out there, I believe PM Hospital charges on a sliding scale, and I know a couple of the L&D nurses there- no guarantee that we would get one of them, but it could possibly be a cheaper option, if you end up with a hospital birth rather than the birth center, and if we could get one of the folks I know up there, it would be a bonus...
Since my daughter had brain surgery last year, I know all about the astronomical cost of health care and paying for years to pay off procedures... when there is really only one good option, and the rest
are substantially worse options, you say "to heck with it, it's only money" and go for the best care- but when there are a couple of different similar options, and one is substantially cheaper than the
other, there is no point in going into more debt than necessary.
For example, there were NO pediatric neurosurgeons "in network" on our health insurance plan, so we had the choice of paying out of network (30% of brain surgery is a lot!) or going to a general
neurosurgeon that was in network and only paying 10%. We determined that we didn't want to turn our toddler over to a brain surgeon who didn't specialize in tiny little folks- adults and children are NOT the same, as far as we were concerned with regard to brain surgery, so we felt that the difference was worth the money... and we WILL be paying for it every month for many years, but we
still gladly count it as "worth it".
But, on the other hand, in another example, we were going to have to wait for an MRI for almost three months to have it done at the Children's hospital, or we could have it done at MC Hospital in two weeks plus it would be less money. Although the folks at Children's ONLY work with children and the folks at MC did radiology and anesthesia for everyone, not only children, we didn't feel that the difference in care for having an MRI done was worth the extra time and money for that particular situation, so we went with the faster/cheaper option.
So! Going to Dr. D and paying a consult appointment fee is an investment in hopefully getting to have a birth center birth- most likely well worth it.
But if it gets to the point of a choice of being induced in a hospital by Dr. D at MC hospital or being induced at a hospital by someone else at PM Hospital, I don't know. You might want to consider
how different the care would be vs how different the price would be when you are making your decision since you are cash pay.
If you come to that point, and ask your informed consent questions - especially "is this an emergency or do we have time to talk about it", "what are the alternatives to the course of action you are suggesting", and "what would happen if we wait right, and six hours is likely fine and definitely a few minutes of privacy to discuss the issue is not a problem at all, or start out with a few minutes and keep asking until you get to the "how long to wait is too long" answer)... and even Dr. D, who is at the more liberal end of the interventive scale is saying induce, then you need to choose: is it valuable to you to be induced by her, or would somewhere else work just as well in your mind?
If it comes to that point, which I am still hopeful that it will not, and I believe M and you are also both still hopeful that all this line of thinking will have been for nothing... but if it does get to that point, it
might not have hurt for you to have checked with MC and PM and compared their postpartum policies with regard to baby/mommy separation and rooming in (if those are important to you), their prices for various procedures (epidural, vaginal delivery, cesarean, private room vs semi-private) and such matters. I imagine that Dr. D would work with you financially but to what extent I do not know- you might inquire when you consult, if she believes you need to transfer care to her from M.
Anyway, I have only worked with Dr. D one time, with a couple who transferred after the birth. I would have characterized her manner as brisk, definitely, so I can see how you perceived that as uninterested/uninvolved. Certainly she didn't seem to have an unhurried, warm/cozy bedside manner. BUT- On the other hand, she does willingly back up midwives, and she did not push for
unnecessary procedures with my previous client, and she WAS pretty liberal with regard to my client's care... like, she had a small tear but Dr. D didn't think it needed suturing (some care providers seem to like to suture) and indeed, all healed well without suturing so she was right... she didn't feel the need to admit my client (even though the triage nurses had been trying to do so for
hours) based on her symptoms and instead discharged her because she felt it was safe and wasn't hung up on "hospital policy" or "just in case" when she didn't feel it was needed... that kind of thing. So you might also want to consider how important "clicking" with your care provider is and how important bedside manner is, to you, vs being philosophically in tune with but not personally. Both personally and philosophically is ideal, but if you have to choose... only you know where you come down on weighing those factors.
So I am NOT trying to talk you out of Dr. D or MC. I have no reason to do so, and in fact, other than my top priority being hopefully you getting to have the BC birth you want, safely and healthfully, I don't care either way with regard to Dr. D/MC or someone else at PM, I will cheerfully go wherever is needed and work with whoever is needed.
I just want you to feel that even if your first choice is not available to you, you DO still have choices and can still have some control over what happens. Feeling like you were able to make autonomous
choices and were not pushed into any particular choices you didn't want, can go a long way to making a woman's birth experience one she remembers as empowering and positive, even if it didn't exactly go as she wanted. Does that make sense?
Some people like to plan for every contingency so that they don't feel "taken by surprise"- I thought you might be one of these, based on what all you included in your birth plan. Other people do not want to consider any outcomes which are undesirable to them, considering that even thinking about them might plant the possibility in their psyches, so they would rather focus only on the outcome they desire and put out of their minds any other possibilities. To them, "crossing that bridge if/when they get to it" even if they aren't very informed about the bridge at that point, is much more desirable than thinking about negativity. There is no "right" or "wrong" way to do this, just
whatever works best for each individual.
If you are more of the "plan for contingencies" mindset and want to discuss more options/strategies you might have open to you in the event of a hospital birth, let me know and we can brainstorm.
Otherwise I will just continue focusing on the birth center plan!
DDR By: delilahdr1 |
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| 08/01/2005 2:46 PM |
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Good news! My client had her baby this morning at the birth center- her BP stayed stable throughout her labor, and she gave birth naturally, no drugs, over an intact perineum in spite of baby having two nuchal hands! They are thrilled and so am I- she did great!
Thank you for the support- I couldn't be happier at the outcome. She told me, "It wasn't as hard as I thought it would be", which is the kind of thing I love to hear a first-time mom say after labor!
Delilah <- tired but happy By: delilahdr1 |
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| 08/01/2005 3:16 PM |
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Yay!  By: Henci Goer |
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