Sunday, March 9, 2008


Let's talk abut trust. Is it possible to be well informed but still have trust in your provider? Every now and then I get a patient who is so adamant on doing things their way to the point of unsafety. I certainly believe that women should be well-informed and an active participant in their healthcare. I love it when women come in and ask good questions and express their thoughts and concerns openly. It warms my heart and I try to foster this relationship with every woman I see in the office or on L&D.

However, occasionally, I get a woman who is so deadset on a vision in her head of what her childbirth experience will be that I wonder just what they have been looking at on the internet. For example, I remember a couple I worked with who would not let the nurses on L&D even auscultate the baby. I went in to talk to them and explained that even if they were having a home birth or at a birth center, that the fetal heart tones would be auscultated periodically. They finally consented to this. I've had other patients come in either prenatally or to L&D with very set ideas on how things will go.

Now, I am certainly not unreasonable. If a couple has planned natural childbirth then they don't need an IV, they can be up and about, in the tub, eating, etc. These things are not a problem. But for example, a woman showed up for IOL at 41.5 weeks. Now, we typically offer induction of labor at 41 weeks. If a patient wants to go longer, we inform them of the risks and let it be their decision. This woman was already dilated 5cm (was told this in the office) but the baby was ballotable (head still floating). She wanted an AROM (artificial rupture of membranes) induction (break the water in order to create stronger and more frequent contractions). This was her second baby. She was insistent with the nurse that she call me and would not allow the nurse to check her prior. I was not in the hospital, and I live 45-60 minutes away. I was off call in one hour when she called me. She tells me what the patient wants...AROM, no pit (synthetic hormone used to induce labor), no IV. She didn't want anything from us other than for her water to be broke. Ok, that's fine. I grumble about having to head to the hospital and being off call by the time I got there but told the nurse to check her and I would head in that direction (we have a WHNP who doesn't always do the most accurate vag exams and I wanted to know the station). She calls me back 15 minutes later (what the hell took so long???) and the patient was indeed 5-6cm...but baby's head was far to high to break water. If the head is still floating, then you worry about a prolapsed cord which is a ticket, non-stop, to cesarean section. So I tell the nurse that there is no way I will break her water. The patient ended up going back home and was supposed to come back the next day (I agreed to this).

So what's my point? It comes down to a trusting relationship between the provider and the woman. It's teamwork. It's not a dictatorship, where one party calls the shots and the other should just meekly follow along. The worst is when a woman comes in and says "my massage therapist/bradley instructor/bank teller says I should...". This has happened. I know this will sound uppity and all, but I am pretty damn sure I went to school longer than a massage therapist and likely have caught more babies than her. A woman should have a provider that she trusts to answer her questions honestly and accurately. In return, a provider should be able to trust the woman to be forthcoming and honest about her plans and intentions. I had a woman come in around 20 weeks, we hadn't seen her since her initial visit at 8 weeks. I asked where she had been, she informed me that she was planning a homebirth but did want an ultrasound. Ok, fine, not a problem. I ordered her ultrasound, wished her well, and told her to let us know if she needed anything. This I can deal with.

Anyway enough! Words of wisdom for anyone seeking care during pregnancy. Trust. If you can't trust the midwife/doctor/massage therapist that is providing care...find someone else!!!!


Bobby, not the liver said...

Hey, stranger! I thought you were gone! I will make you a button and re-link you . Great to hear from you.

PE Mommy said...

It took me a LONG time to trust my ob. I don't think I trusted him till after my daughter was born. I totally trust him now.

Ciarin said...

pe mommy, why do you think it took you so long to trust your OB? I think, as women, we often have very good instincts about our bodies and our care. I have tons of exposure to various healthcare providers between my husbands' heart problems and my own health issues to know when someone feels right to me or not. Maybe that very experience is what helped develop my instincts in this area :)

Yehudit said...

Just out of interest..what risks do you explain to women who decline induction at 41 weeks gestation? There are two ways to explain the issue: one is to say that their relative risk of stillbirth doubles, the other is to say that their absolute risk of stillbirth rises by 0.1% (from 0.1% to 0.2%). How you explain the risk makes the hugest difference between a woman thinking her pregnancy is now pathological, that pregnancy beyond 41 weeks is dangerous and that her baby is going to die. In the UK, most hospitals don't start induction until at least term+10, and plenty hold off until term+12 or 13.

Did the woman (patient?) have the option of prostaglandin induction and keeping her membranes intact? It's not usual with cervix of 5-6 cm, but then, if she's not contracting *at all*, a small dose (1mg) of dinoprostin will likely start her off.

Or is she in fact in labour already (unusual not to be with cervix dilated to 5-6 cms), in which case - why not just allow her to continue to labour? (no induction anyway, anything you do will be augmentation), warn obs of high head (just for theatre readyness) and help for her to progress...the biggest issue I can see is, what's stopping the head coming down?

You wouldn't use oxytocin (pitocin in the US, syntocinon in the UK) with intact membranes anyway, would you? (And if you would, why? Surely that's not evidence-based?)

You worry about cord prolapse with ARM, but not about sending her home with a 5-6 cms dilated cervix and a high head? Her membranes could rupture and then she could equally well have a cord prolapse in community - how is that okay?

If you want to get the head down, what about a controlled ARM? Also, why is the head high (position of placenta? shape of pelvis?)

I just don't get this story really. You have a woman who is 5-6 cms dilated apparently not in labour (I conclude, otherwise, why induction?) and you think you need to induce/augment? I can see the worries about the high head, but can't see the worries about declining induction at T+12, given that she's already 5-6cms.

Ciarin said...

Thanks for the post Yehudit. In response...

I just did some researching around on gestational age and complications. I was interested to find that the evidence for induction at 41 weeks is only rated B. I also found more articles that basically said increase in intervention did not equal improved neonatal outcomes. Anyway, my point being that between your comments and my own research my eyes were opened up a bit better. Unfortunately I work in an office where most providers push for that IOL by 41 weeks. I plan to work on this.

As far as the woman who wanted her water broke...

I don't know if she was contracting 'at all' - I would assume she was but was hoping AROM would further things along a bit faster. I was not physically there so never had met or spoke with this woman. I did not schedule her for induction or augmentation as the case may be. I believe this patient was a multip so no indication that there were any pelvic abnormalities. Vertex was also verified by ultrasound. Placenta well out of the way. (I asked, thinking along these same lines).

Practice in the US is quite different (not to be read as better by any means) than UK. Pitocin is used all the time without ROM. Comparing US to UK is comparing apples to oranges. We (meaning as a whole ) do many things that aren't evidence-based, some things good and some bad. There are many parts of midwifery care that is not evidence-based. Part of this care is considered an art - how do you research and define art? An example - ambulation during labor has not been shown to be beneficial in speeding labor up. So why do we encourage it anyway? Because it gives mom a sense of control and comfort at times. Sounds like a good enough reason to me. I'm very in support of evidence-based practice...but that isn't always the bottom line. As far as pitocin is concerned - used ALL the time here without ROM. In fact, in my personal experience, multips tend to be high until very active labor when the baby descends rapidly.

As far as sending her home...what would you have suggested I do with her given she wanted nothing else but to be ruptured or to go home? I can't force her to stay and had I tried to do so she likely would have signed out AMA anyway. She lived five minutes from the hospital. My OB was ok with her going home.

My OB was planning on doing this (not me - too big a chicken-sh*t) the next morning but he simply didn't want to go in that evening. I have no control over that.

While I appreciate your comments, I believe you may have missed the point of the post, which was about trust.