Archive for November, 2011

A: whoever will give the laboring mother a sense of calm and expectation. She thinks about being in active labor in the presence of a particular person (her mother, her best friend, her sister, her father-in-law, etc). When she imagines that person with her in labor she smiles. She knows that she will feel more energized, more secure if this person is with her. Invite this person!

Conversely, if a pregnant woman thinks about being in active labor around a person and finds herself wondering what that person will think or how that person will behave, if she frowns even just slightly while she imagines this person there, this is not a person to invite.

This process changes from birth to birth. The right birth team for your first labor is probably different from the right birth team for your third labor. We change. We grow. We need new kinds of support.

Anyone who wishes they could be with you in labor but who is not invited should have a special job to do during labor. Some of my favorite assignments for such people (grandparents, often):

1. Bake a birthday cake for the baby

2. Purchase the day’s newspaper and a lottery ticket

3. Have dinner ready for the family when they arrive home

4. Send them to the store for some absolutely necessary supplies: more diapers, more wipes, more baby blankets, whatever you can imagine needing. Just make it sound IMPORTANT!

5. Serve as the conduit for information to the rest of the world during labor. The dad or doula can make one phone call or send one text to this person who can then broadcast any information to the world that the birthing family desires.

6. Write a letter to the new baby on its birth day to welcome her or him to the world!

Why do I believe that a woman’s intuitive knowledge of who will support her best is the way to decide? I have a simple answer. A woman’s body is designed to shut down labor if she perceives even the smallest threat to herself. It doesn’t matter how much you love your mother or your friend. If you feel judged by this person in any way, you can compromise your labor. It’s not worth it. Be selfish! Consult your inner wise self and no one else.

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My sense is that informed consent is only as good as the people enacting it.

After my last post (inspired by an obstetrician’s blog post about how inane the IC process feels to him in its current form), I remembered a recent experience during which the informed consent process seemed especially silly. The anesthesiologist was required to get an IC form signed by a woman in early labor who was planning a natural birth. She rolled her eyes as she gave it to him. She was very angry that she had to see an anesthesiologist during her natural hospital birth. It sort of negates the whole plan of “not being offered pain medication unless I ask for it,” eh? Given that informed consent is, in part, about acknowledging the decision-making power of the patient, it felt especially ironic that she had no power to make the decision not to be offered pain medication. (Our hospital requires this in early labor.)

It  made me think about a distinction we make in anthropology between “ideal” and “real” forms. In its ideal form, informed consent is supposed to help all the parties involved. There is a certain expectation that information will be presented neutrally, I think, so that the Decision Maker (in this case, a laboring woman) will be able to make her own (uninfluenced) decision.

But that ideal is impossible to attain because the person asking the patient or laboring woman to sign a form is exactly the person who is advocating a particular course of action/treatment. There’s no neutrality there by definition. So as some doulas and midwives say, it can feel more like “informed coercion” than “informed consent.” When it works like that, it can feel inane to all involved, I think. Why go through the motions if they are nothing more than motions?

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Dear Academic OB/GYN,
I am new to reading your blog, but really enjoying it! The issue of “informed consent” is really a unique issue for us here in the United States. (For my blog readers, you can see Academic OB/GYN’s post on the surgical consent form which follows below or head over to her blog at http://academicobgyn.com/2011/06/20/on-the-surgical-consent-process/).

I’ve worked in Russian hospitals (as a midwifery apprentice and as an anthropologist) and in Canadian hospitals (as a doula) and their approaches were so very different in tone and feeling! There was no informed consent process in the Russian hospitals (in 2000-2001) and the process in Canada felt much more like what you describe at the end of your post: a friendly chat.

That said, I think it is a fault of how we all in America — doctors and patients, professionals and laypeople — imagine medicine that creates a problem. Doctors are people (I love reading books like “How Doctors think” or “Complications” to remind me of that!), but sometimes we all pretend that doctors are really computers. We do not expect human indecision or unknowing or, God forbid!, human error. We expect perfection. This is true in many arenas, not just medicine. Our culture is very black and white. If something goes wrong with anything, someone must be blamed. Shades of gray or the idea of joint responsibility don’t fit our cultural expectations so well.

Finally, I am not sure that all doctors are capable of talking the way you describe. Some are; many are not. It is not just the moment of getting a signature on an informed consent form that matters. How doctors talk (or don’t talk) with patients matters all the time.

At the last birth I attended as a doula, a medical resident took over from an experienced midwife when the baby’s heartrate was non-reassuring for too long. She never introduced herself to the woman giving birth or her husband. She cut an episiotomy and put in an internal monitor and started using a vacuum with not one word of explanation. There were several seconds of silence in between contractions, so it was not because of lack of time. My client will never see that doctor again in her life. That doctor will never know how her treatment felt to those of us in the room. But as the doula, I have listened to three conversations in which my client is trying to understand what happened to her “beautiful birth” in those minutes. With just a few words, I think my client could have had it all: medical help in a possible emergency AND a beautiful birth.

I do not even entirely blame this doctor. We have created a medical education system that penalizes many doctors if they try to be well-rounded, emotionally-intelligent, full human beings. Probably, if this doctor experienced a major obstacle in her personal life in her first year as an intern, she was not going to be given empathy, kind words, time off to relax and rejuvenate, understanding, etc. She probably faced a spoken or unspoken expectation to tough it out. What we reap as a culture, we will sow.

In Russia, there was certainly a divide between doctors and patients. But in one area, I watched with amazement at how quickly the barriers fell down. That was in the area of pharmaceutical treatment. Diagnosing was the purview of the physician; but treatment was often a mutually-negotiated conversation that occurred between equals. Why is that? Well, most of the doctors and patients shared a common, deep knowledge of herbs. Everyone at my birth hospital seemed to share a tacit understanding that herbs were the preferred method of treatment, if possible, and pharmaceutical drugs (like antibiotics, painkillers, etc.) were only a second option.

The entire culture expects urban Russians to spend time gardening and foraging in forests (for mushrooms, herbs, etc.) as a normal part of life. It’s the best way to spend a summer weekend in Russia! That ubiquitous hobby has a strong impact on the way that doctors and patients interact in the maternity ward. Many Americans hear me talk about this and immediately jump to attack the Russian medical system. I know there are problems there (as there are here), but my experience was in a beautiful, well-run birth hospital with intelligent, capable doctors, midwives, and nurses that boasts excellent outcomes. And, in this one arena at least, there was a model for doctors and patients being able to discuss treatment options as equals.

Those consent forms, I think, are supposed to remind patients that they share in a joint responsibility with their caregivers for their own healing. Perhaps they also remind physicians that interventions are never risk-free. But in the end I believe that real conversations between two real people are the best protection: from lawsuits, from errors, from decisions we later regret. Legal documents are a mere shadow of that human connection.

Here’s the blog post:

Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.

As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.

While this consent process is quite standard, it just seems a little ridiculous to me. Its a bit like asking your neighbor bring your son home from school, and having her say “we may get hit by another car, I might run a red light, we may run out of gas on a train track, there might be a meteor that hits the car and kills us all…. but don’t worry I am a good driver and your son will be fine.”
The fundamental reason we do these consents is that we believe that in some way they will protect us in a lawsuit if something bad happens. For example, let’s say somehow I transect a ureter in my patient’s hysterectomy, I can say “See – I said this was a risk of the surgery… it wasn’t my fault!”
But isn’t that a bit ridiculous? Is telling somebody that something bad could happen actually a defense if that bad thing does happen? In some cases a problem is truly random, such as the development of a pelvic abscess after a hysterectomy, but in other cases it is not. There is almost no situation in which I could cause a ureteral injury and have it not be a surgical error. If it happens, I did it – and it was a mistake. Ureters are damaged in about 1% of hysterectomies, but its not like they magically get injured in 1% of cases. In 1% of cases the surgeon makes an error.
When I was a resident I worked with one attending that thought along these lines as well, and had a very different consent process.
“We are doing X surgery because of X. I’m a good surgeon, and think I can do this surgery without a problem. You need to sign this paper or the hospital won’t let me operate. I think it will go well, but anything can happen, and if it does and you think its my fault you can still sue me.”
This all seemed very glib the first time I heard it, but I have to say I have always had a lot of respect for that attending’s honesty. He was telling it like it really was, even though it wasn’t necessarily the smoothest way to go about it. He was indeed a very good surgeon. His partners thought he was a bit nuts, though.
The trouble with the standard consent process is that it doesn’t deal with the real issue; errors do occur, and physicians cannot be perfect. By naming error-driven events as statistical occurrences, the process supports an expectation that surgeons will never make errors, and thus the corollary that any surgical error is a de facto breach of physician’s fiduciary duty.
Every time I do a standard consent process, I think about doing it differently. Perhaps something like this:
“We are doing X surgery because of X problem. I am well trained to do this surgery, and think I can give you a great chance at an good outcome. Your surgery is something I know I can do well, but I cannot guarantee that you will not have a problem. I can only guarantee that when I do your surgery I will be well rested and that my team and I will do our best.
Sometimes when bad things happen during or after surgery it is a random event. There are certain things we can do to reduce these events, and we will do those things. Another kind problem can be because a member of my team or I makes a technical error. While I do my best to operate perfectly, it is possible that I could make a mistake. I have occasionally done so in the past, and will no doubt do so again in the future. As I have always learned a great deal from these rare mistakes, I hope to think I will never make the same error twice. Fortunately, almost every error is recoverable, and I know how to make those recoveries. If we have a problem, I will be there to fix that problem and help you through whatever recovery is necessary. I will explain the problem to you, and if I know, I will explain how it happened.
(now sign this paper or the hospital won’t let me operate )”
I often wonder if the common legalese consent process we go through actually protects us. Ultimately, we are bound to meet the goal of “The Standard of Care”, and we don’t get to define that standard on our consent form. Lawyers love to say that this standard is readily viewable in any textbook, but in reality its pretty grey. The exact definition changes from state to state, but usually is defined as what another reasonably practicing physician of similar training and situation would have done in the same situation. Fortunately, reasonably practicing physicians of similar training and situation also make mistakes from time to time, and usually lawyers and juries recognize that. As long as one recognizes the mistake and does the right thing from there forward, usually one has a reasonable defense.
So let’s just say that up front. We are well trained, and we do our best. If we screw up, we’ll let you know that, and we’ll fix it. Now sign here.

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In my last post, I suggested that if you know a doctor, nurse, or midwife who has supported a woman well in birth that you send her/him a thank you note. EnjoyBirth commented that she always writes thank you notes when she is a doula and points out the positive things that hospital staff have done during the birth.

That is one of my secrets as a doula that should probably not be secret. I ALWAYS carry a pack of ten thank you notes in my doula bag. I write at least two myself and leave the rest for my client in case she wants to write some thank you notes t before she leaves the hospital. I usually bring some small gifts she can leave with the notes: chocolates or small lavender mist bottles (which are easy and cheap to make at home).

Thanking birth professionals for their work is good for everyone. Of course, we all know how wonderful it feels to be noticed and appreciated. 🙂 I believe it helps improve doula-hospital staff relationships, too. Many doctors, nurses, and midwives are happy to welcome doulas to birth teams and they know we have a lot to contribute. Some, as you may know, wish we weren’t there and go out of their way to make us feel unwelcome. I try to assume that they have had a bad experience in the past. Though my first responsibility is to the laboring woman who has hired me, I always strive to make allies out of the hospital staff if at all possible. I’d like to leave them with a positive impression of doulas. Thank you notes and gifts seem important in this regard.

Finally, no matter how a birth goes, I remember that hospital staff members have all dedicated years of their life to learning their craft, often at considerable personal sacrifice. Obstetricians have to spend a minimum of eight years, eight INTENSE years of more than full-time work (sleepless nights, on-call weekends, etc.) to become doctors. Because of the intensity of training, they have less successful marriages, fewer children (and often no children, ironically!), higher suicide rates, higher rates of depression and substance abuse. They also start being an independent practitioner with an average $157,000 of debt and must pay exorbitant medical malpractice insurance fees ($150,000/year on average and in some areas more than $300,000/year. Obstetricians are the most sued doctors in America.

I think of all they have given up — and yet how happy I am that they are there to back up normal birth in our country. I understand that it is hard for many obstetricians to support a natural labor without intervention. That is frustrating for all of us who love natural birth and believe that birth is usually safe. Yet even those of us who love natural birth know that there are some women and some babies who must have access to life-saving medications or procedures or face dire consequences. It is rare, I know. But I find that carrying gratitude in my heart for ALL obstetricians is good for me.

Those hospital staff members are there for us in our hour of need and for that I am grateful. It doesn’t mean that I intend to use their skills unless I really need them. As a doula, I help most of my clients learn how to say “no” to many, many common interventions. Still, it works better when we say “no” with humility and gratitude.

Thank you notes are just always helpful and never hurtful. I recommend thank you notes as a hospital “intervention.”

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As a doula, I often hear exchanges between pregnant women and doctors that sound something like this: “I’d really like to try for a natural birth if at all possible.” “Oh, yes, natural is definitely best if it’s possible. But the important thing is having a healthy baby.” Does it have to be Either/Or? And if we think of these aspects of birth as separate and unequal, how does that influence birth?

Biomedical science pooh-poohs the idea that emotions and mental states are integral to health (or illness). Yet when we are not sitting in a doctor’s office, most of us know that our emotions are directly connected to our physical experiences. Ina Mae Gaskin offers the simple example of blushing. We feel embarrassed; we blush. What about crying? We feel sad (or sometimes mad) and we produce tears.

Having a “safe birth” means far more than monitoring our physical symptoms. In many hospital births, no one is trained to pay attention to more than the biochemical level of birth. If something looks sort of “off” at the physical level, no one is ready to reassure the mother, “You’re safe. You might feel scared. Breathe. Keep working. You’re doing awesome and your baby is coming. It can feel scary, but you are OK.”

One of the most important physical indications of whether birth is proceeding “safely” for the baby is the baby’s heart rate. But our heart rates and our babies’ heart rates are not the same as, say, the gas meter in our car. In our car, the gas meter indicates a simple, mechanical truth about the car: how much gas is in our tank. If we monitor the gas meter, we will have knowledge about what we should do (pull over immediately to the nearest gas station or not).

But the indicators, like a fetal heart rate, that we can “measure” during labor are different. Birth is not a purely biochemical process; it is a biochemical process AND it is also a mechanical, emotional, relational, and often spiritual process. What a woman feels about her labor actually impacts how the birth proceeds. Gas meters don’t feel anything and their emotional state does not affect the production of any automobile hormones. Humans are different. If we feel scared, we produce more hormones like adrenaline, which shut down labor hormones, and we produce fewer labor hormones (like oxytocin). Adrenaline and other such hormones can have a profound effect on our physical symptoms and, many believe, on our baby’s heart rate.

[Ironically, sometimes even the physical mechanical level of birth is ignored because all the focus is on biochemistry. Sometimes a change of the laboring mother’s position can shift the baby’s weight off the umbilical cord and change a non-reassuring heart rate to a perfectly normal heart rate. I attended a birth recently where all of us forgot this fundamental idea for two hours. When I finally remembered to suggest a position change (for a mother on an epidural), the baby’s heart rate changed back to normal and stayed that way.]

How we feel ABOUT giving birth is AS IMPORTANT as having a healthy baby. There is no either/or dichotomy. If a woman is truly empowered in labor, she will feel fundamentally at peace with the decisions she is making, including any decisions SHE might make about using interventions. I have attended  a fully natural birth with minimal medical intervention at which a woman felt traumatized by her experience and I have attended C-Sections at which women felt peaceful and empowered. How we feel depends on whether we are treated holistically as intelligent, emotional, spiritual, physical beings, not just a mass of biochemicals that need to be measured constantly.

I know that doctors have seen babies die. They have seen babies born with serious problems. Some babies spend weeks or months trying to survive in the NICU with tubes all over their bodies. There are real tragedies that doctors, nurses, and families have to deal with. I know that when a hospital staff member treats a laboring mother as something less than human and when they laugh derisively at the idea that her “experience” was not positive because she ended up with a healthy baby, so what is she complaining about, they are thinking of those tragic outcomes. Ironically, the feelings that sometimes determine the course of labor decision-making are not the mother’s feelings, but the feelings of hospital staff disguised in the form of “doing something.” But because we do not put much emphasis in medical school or residency on identifying or coping with difficult feeling states, this remains virtually an invisible and unnamable problem.

I am grateful for the medical skills of hospital birth professionals. We definitely need them! Yet how much more effective would these skills be if they were always, everywhere accompanied by emotional skills, such as an ability to express empathy for how a laboring woman might feel in any given situation? Because I run mom-baby groups for moms of newborns and toddlers, I know that how a woman is treated in labor affects her FOREVER. The end does not justify the means in this case. Treating women with deep respect, empathy, and reverence is MORE important during what appears to be a medical emergency. This is when women need such support the most!

I have been in labor rooms where medical personnel were able to communicate this sort of respect and empathy and reverence, even in the middle of emergencies, and I have been in labor rooms where not one hospital staff member was able to muster such a positive vibe at any pont.

“Having a good experience” and “being safe” are not separate categories. They are inextricably intertwined. When we expect moms to be happy about their birth experiences because they have a healthy baby, we are sticking our heads in the sand. Labor and birth are profound rites of passage that women remember, in a dream-like, deep way, for the rest of their lives. Research tells us that how a woman feels about her labor dramatically impacts her post-partum ability to mother (to breastfeed, to feel competent, to avoid depression). We all need to pay attention to the multiple levels of labor simultaneously. Instead of a dichotomy, we need to reimagine birth experience and birth outcome as the SAME THING.

If you are a doula or a woman who has given birth and you know a doctor, nurse, or midwife who is able to do this, please let them know that you noticed and appreciated this skill. We need more of this! Please share your stories about this either/or thinking and times when this has been transcended in the comment section!

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