Tag: medical interventions in childbirth

How to Use Hospitals’ Whiteboards as A Coaching Strategy

Exciting steps towards improved communication between L&D nurses and their patients

I’m constantly searching for coaching props and strategies that can help me coach expectant parents throughout pregnancy and childbirth. I have been developing tools and strategies for some time now and excitedly shared them with the community of birth support pros in previous posts and in my book. So, you can imagine my excitement when I came across a few resources affirming the use of white dry-erase boards in L&D for improving communication and maternal care.

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The Birth Plan from a Coaching Perspective

Is birth plan the goal or the strategy? 

When birth workers, such as doulas and childbirth educators, first envisioned the birth plan in the eighties, the main idea was to help expectant parents prepare for the physical and emotional aspects of the birth process, explore how they want various situations handled during their actual birth, and provide a tool for parents to communicate with each other, their care provider, and the hospital staff prior to the birth (Simkin, 2007; Simkin & Reinke, 1980). As sometimes happens, the mean comes to be associated with the goal, and as such, expectant couples and some birth workers, associate writing the birth plan with achieving it. This association may evoke some unexpected outcomes: 

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Coaching towards a Successful VBAC

What are the additional challenges of a birth giver who wishes for a VBAC?

While the coaching strategies are valuable in supporting and leading every expectant woman who would like to give birth healthily and experience high levels of satisfaction, they are even more crucial when supporting and leading a birth giver who wishes for a VBAC because of the additional elements or challenges she faces.

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Coaching Your Birthing Clients after an Alarming OB Visit During Birth

  Last week I was supporting a lovely client; an educated and committed mother who hired me as her doula for her first birth. We went through a series of prenatal coaching sessions and drew her belly map. She was practicing the daily activities to encourage optimal fetal position, as well as labor support tools with the guidance of my DVD Practicing for an Active Birth’. She had prepared for her birth. As sometimes happen, the onset of her labor was unpredictably challenging; her water broke and after 36 hours- some spent at home and some at the hospital, she was mostly cramping, but not contracting. After about three hours in L&D, the on-call doctor came into the room and began talking about administering misoprostol. When she called me she said that the doctor has explained to her that ‘taking the medicine will not impact her desire for natural childbirth. Coaching my birth client after an alarming OB visit during her birth is a challenging situation for doulas.

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The Trauma of a Doula who Witnesses Abuse in L&D

I wish I would never have to write this blog post, but I am afraid it is the only way for me to heal my own trauma. I witnessed abuse in the L&D room. I felt helpless. I felt I had to remain silent in order to stay in the room. This experience made me think of all my doula sisters who are witnessing abusive experiences all over the world.  They must remain silent in order to stay in the room. I want to be the gatekeeper in L&D. I am like the news reporters who report crimes against humanity and wake the world up to take action.

Can birth support become a traumatic experience for doulas?

Verbal abuse in L&D: threatening, scolding, ridiculing, shaming, coercing, manipulating, mocking, dismissing…

The terms Vicarious traumatization (VT), Secondary Traumatic Stress (STS) and Compassion Fatigue, are professional terms describing the trauma of caregivers. The trauma results from empathetic engagement with traumatized clients and their reports of traumatic experiences. Even this term cannot describe the trauma of the doula who witnessed her birth client being abused. I did not hear the traumatic birth story, I was present when it happened.

I want to stress the fact that this childbirth could have been considered a beautiful, healthy and positive birth process if it weren’t for the abusive behavior of the doctor. In order to convince you of that, I ask that you read the birth story below twice- on the first reading, read only the black text; on the second, read the parts that are in green italic letters as well. The birth story is at the bottom of this post.

I am not the first one to report abusive behavior in L&D. As part of my healing process, I searched for articles about abusive expressions in L&D and found them in the two languages that I speak and read: English and Hebrew. A few months ago, an article came out in one of the most prestigious Israeli newspapers describing the horror and abuse of Israeli birth givers experience in L&D.

We (doulas, patients, L&D nurses) tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

The topic has been researched and studied

I discovered this article: Abuse in Hospital-Based Birth Settings, by Susan Hodges, MS, to be very helpful in achieving my goal – defining the trauma of the doula who witnesses abuse.  Hodges describes the expressions of labor and delivery abuse as well as the dilemma of the abused patient: Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient’s self-esteem while enhancing the abuser’s sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a “patient.” Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

By using the word ‘we’ in the last sentence Hodges implies that patients and doulas, or other witnesses, are in the same position – feeling helpless and rationalizing this behavior as ‘poor bedside manners’ – which we tend to be more forgiving towards, as a society. How many times did you hear the sentence, “He has poor bedside manners, but he is a great doctor”.

I believe that that the doula position is different in regard to an abusive environment in two aspects:

  1. Doulas know better than their clients on what to expect: While the doula and the expectant couple can both equally recognize rude behaviors such as “ridiculing, shaming, coercing, yelling, belittling, mocking, dismissing…,” the doula is more knowledgeable and experienced in the field of birth support and is far more equipped to recognize threatening, manipulation, and lying.  Identifying these in Labor and Delivery will require basic knowledge of the field terminology, ‘evidence-based care’, and a basic understanding of causality in childbirth. This means that the doula can detect and identify abusive behavior that her clients may perceive as an act of care. Hodges points out the need to educate birth givers in order to reach an informed consent:Women who are well-informed and ready to ask questions about procedures, treatments, and interventions during labor can address some deficiencies of “informed consent” and not be hoodwinked into unnecessary interventions.“ However, this kind of education breaks the rapport and trust between birth givers and representatives of the medical system. This situation is described by Christine Morton as the doulas’ advocacy dilemma in her book ‘Birth Ambassadors’, and there is a general agreement among doula certifying organizations doulas should avoid initiating a tug-of-war in L&D.  Additionally, this type of education seems to work prenatally, but is flying out the window when birthing individuals are overwhelmed with fear.

A doula who speaks-up is taking the risk of becoming an unacceptable or unwelcomed at this facility in the future

  1. Doulas lack the ability to file a complaint or take any affirmative action: Several organizations, such as CIMS, LAMAZE, and Citizens for Midwifery, encourage birth givers, who suffered abuse in L&D, to file a complaint following the birth. According to Hodges, this action is not only with the purpose of reducing the expressions of abuse in L&D, but instead is perceived as an act of empowerment. “Filing complaints alone will not solve the problem. However, women, I’ve spoken with who did so felt empowered, and it helped them acknowledge to themselves that they had been mistreated and were not at fault. Well, here lies a big difference between the patient and the doula. Doulas remain silent.  A doula who shares her negative experience with a caregiver or with hospital staff is taking the risk of becoming an unwelcomed persona in this facility.  We are lucky to have our doula support circles, and we can always cry on our peers’ shoulders and get their support, but this is equivalent to the birth giver sharing her trauma with a friend, and this might not be enough for true healing and empowerment.

Please read the story twice

Now that I’ve shared some general insight about abusive behavior in L&D, here is the birth story that I promised to share with you. For your own benefit, please read twice as previously requested.

My client, Beverly, woke up at 4 am in a puddle. Her first labor began with a rupture, and her contractions began shortly after. By 7  am her contractions were around 50 seconds long and about 5 minutes apart. At 10 am, her contractions intensified and occurred every 3 minutes for about 1 minute at a time. At that point, Bev noticed that she was bleeding and decided to meet me at the hospital.  Upon arrival at the hospital, she was vaginally checked and measured to be 4-5 cm dilated and 90% effaced, and after a 30 minute EFM, we went to the shower. Bev was breathing beautifully and handling her birth with grace and confidence. Her OB was out of town, and the on-call OB from his group showed up and went into the shower to listen to her lungs. After the OB visit, Bev’s partner came out of the shower and shared that the doctor was commenting on the couple’s request to delay the cord clamping, by saying that he can wait only 90 seconds, as too long of a wait can lead to disasters. He shared an article he has just read about the baby’s leg amputation due to a cord clamping delay. I went back to support Bev in the shower, and she shared her disappointment that her OB was not the one to see her through her birth. After a long hour in the shower, Bev felt some pressure towards her anus and was asked to come out and be checked. She was 6-7 cm, 100% effaced, baby in a station (-2).  It felt for her like the right time to get the epidural that she has planned on taking. At 4pm, the nurse started the drip of fluids. Coping with the contractions in the room Bev was convinced that taking an epidural is the right thing for her. She asked for a low dose epidural, but the anesthesiologist has said that preference is, to begin with, a good dose and then slowly lower it. Following the administration of epidural, Beverly’s contractions have totally stopped, her blood pressure went deeply low, and the fetal monitor showed a 4-minute deceleration, which was controlled and recovered with a change of position and oxygen. She had no sensation nor the ability to control her legs. While the nurse and the anesthesiologist were mainly occupied with recovering the low blood pressure and the baby’s FHR, I was concerned with the lack of contractions. I thought it will be wise to prepare my clients for the possibility of administrating Pitocin, reminding them that it is one of the possible side effects of epidural. After 3 hours wait, with no sign of contractions, The OB came into the room and began explaining to the couple that as for now, a process of deterioration of the baby’s brain has already begun. The OB further explained that if they do not manage the birth and bring it to an end than this deterioration can become brain damage. (I am sharing the nuggets of it, as he rambled on and on for a good 10 minutes, sharing ‘studies’ and medical schools ‘All in favor of the couple making an informed decision’. ) When the couple asked for a few minutes to think about all that they have heard, the OB looked me in the eyes and said: ”Just for you to know, under the law of California, any medical advice is considered practicing medicine and you will be in big trouble”.  The couple decided to follow the OB’s suggestion, who has inserted the IUPC and began Pitocin. Following the administration of Pitocin. Bev’s contractions have recovered; by 8 pm she was fully dilated, with the baby still in (-2). A dose of antibiotics was given to the birth giver due to maternal fever and the long rapture. By 10 pm, with the baby in (-1), she began to push. When the baby came down to (+1) Bev was able to feel the pressure building, and she pushed strongly, making progress with each contraction. The nurses changed shifts and we had a new, refreshed and very supportive nurse in the room. As the baby descended, there were a few more declarations that recovered after the contractions were over. The nurse kept encouraging and complimenting Bev for her effective pushing, and then the OB came again to the room and began talking to the partner. In his words, he said, “I know you do not like it when I bring things ahead of time, but I think it is important for you to make an informed decision, therefore I want to talk to you about choosing between forceps and vacuum”. Then he stopped because Bev felt the urge being built and we all attended to her as she pushed, the husband is next to her head and counting, the nurse at her perineum and I stood by her side supporting her leg. The contraction is over and the OB continues talking: ” I personally prefer the forceps, but it is a matter of medical schools, as most doctors these days will use the vacuum…..” and he stops again as Bev is asking for our attention and is pushing like a lioness, I swear. As he went out of the room, leaving the partner to make his decision, the partner asked me what was going on. He felt like one of us is lying to him, not telling the truth.  How can it be that the nurse and the doula are being all excited about the progress, and the OB is asking him to choose between the vacuum and the forceps? The nurse and I tried to reassure him that there will be no need for him to choose.  He was so terrorized and said:” I know the vacuum to be safer for the baby, but I’m afraid to choose against his preference, he might get really angry and decide to end it now with a cesarean”. In order to lead him back to his logical thinking, I began asking questions: ”What do you know about vacuum and forceps”? And then asking the nurse: “Percentage-wise, what would you say is used more here in the hospital?” The nurse was reassuring the dad that he needs to choose based on what he feels more comfortable with.  This coaching conversation took place between moms pushes. I went ahead asking the nurse: “Is there a medical reason that you are familiar with to end this birth with a cesarean now?”, and we both reassured the dad again and again, while all along the mother kept pushing, and — here comes the head!  The OB was called to the room and began dressing. While it was clear that in the next contraction the head was going to show up, he said “Well, because you were waiting so long since the water broke, and as I explained the deterioration has begun hours ago, and there is already maternal fever, your baby will go to the NICU and will stay there for two days for special care”. The NICU team arrived and a few minutes later we heard the baby crying his lungs out. The neonate doctor said: ”Why was I called? This baby boy is so strong, here mama” and she puts the baby on the mother’s chestBev’s healthy and strong baby boy was born at 12:30 am, and he nursed right away. The couple had two beautiful hours of bonding with the baby.

Does Birth Activism Lead Expectant Individuals to Demand Better Maternal Care?

Recently I watched the movie ‘Trial of Labor’, and listened to the stories of three women who wished for a VBAC (Vaginal Birth After Cesarean). It made doubt the approach we, birth activists, take in our efforts to improve maternal care. Especially our continuous attempts to educate and empower expectant individuals by pointing out the flaws of the medical system and its representatives.

What did birth activism look like in the 90s?

I gave birth to my oldest child in 1995. I often say that she was my muse since my first pregnancy and birth experience led me to pursue a career in the field of birth support. I was lucky to go through this journey in the 1990s, as it seems that these years offered women a wealth of information about natural childbirth: Barbara Harper first published Gentle Birth Choices in 1994, the same exact year that Michel Odent published his book – Birth Reborn. Janet Balaskas published Active Birth in 1992, and Marshal H. Klaus published Mothering the Mother in 1993. Henci Goer closed the 1990s by publishing The Thinking Woman’s Guide to a Better Birth in 1999. All of these authors were, and still, are my teachers and mentors, not to mention idols.

How do childbirth educators and doulas use all these resources?

Who can read Harper distinguishes myth from truth about childbirth, and continue to obey the medical authority?

As a childbirth educator, I was referring my students to the books mentioned above as resources. I was thinking – well, who can read chapter 2 in Harper’s book, where she describes the medicalization of childbirth and distinguishes myth from truth about birth, and still obey the medical authority? (Harper, 1994, pp. 51-91). Since 2002, I opened every class that I ever taught about ‘Common medical interventions in childbirth’ presenting Goer’s remarkable observation, at the beginning of her book, that “Obstetric practice does not reflect the research evidence because obstetricians actually base their practices on a set of predetermined beliefs”. (Goer, 1999, p. 3) Again, I was thinking: who can read this statement and the evidence-based information that follows, which refutes the notion that obstetricians practice is evidence-based, and still blindly follow medical advice?

What did birth activism look like since the beginning of the second millennia?

At the beginning of the second millennia, we took birth activism to the movies: Birth as we know it was released in 2006, Pregnant in America was released in 2008, at the same year as The business of being born. Laboring under illusion was made in 2009, and Orgasmic Birth was released in 2008. One would assume that movies are reaching the mass more than books, and expect better results in terms of educating couples about childbirth and leading them to make informed choices, and yet we saw no change in the anticipated direction. After 20 years of birth activism, the statistics of medical interventions in Labor and Delivery are disheartening; the high rates of augmentations and inductions, epidurals, cesareans, and the low rates of VBAC’s and home births break my heart. I believe that many fellow childbirth educators and doulas feel the same way when they think of all the couples they taught or supported that ended up with a cesarean or came back home from a long-lasting birth that strayed from their birth plan. So maybe it is time to take a different approach in order to create the change we strive for?

What’s holding them from making better choices that are based on the evidence-based information we share?

So why are they still not making better choices?

It wasn’t until I became a life coach that I was able to put the finger on what it is that is missing. It is not by means of sharing our knowledge that we can lead a change, but rather by evoking the change in them.  I’m going to paraphrase here on Goer’s observation regarding obstetricians, and apply it to couples as they prepare for childbirth: “Parents’ choices in childbirth do not reflect the knowledge we share with them, because parents actually base their choices on a set of predetermined beliefs.” Just like the evidenced-based knowledge suggested by studies in the field of birth didn’t change obstetricians’ practice, it can’t lead parents to change the choices they make. There is a need for a different mechanism than teaching evidence-based information in order to create change because change is not achieved by the practice of informing, but by the practice of coaching.

Parents’ choices in childbirth do not reflect the knowledge we share with them because they  base their choices on a set of predetermined beliefs

What makes coaching a better practice to evoke this change?

Here are a few differences between teaching, informing and coaching, that might explain my choice to integrate coaching in my practice:

  • The educator is an expert in a field of knowledge.  The coach is an expert in an area of practice, or performance.
  • The educator is delivering a body of knowledge, informing. The coach is providing tools and strategies to enhance the performance in the desired area.
  •  The relationship between the educator and the student is hierarchic, meaning that the educator is an authority, holding a body of knowledge that the student does not possess. In coaching, the relationship is more like a partnership, with the client’s goals, and her journey to reach them, being at the center of the partnership.
  • Educators mostly share information students are interested in and answer students’ questions.  Coaches are mostly asking questions. The coach’s questions facilitate clarity about the client’s goals, needs, and belief system. The coach might also suggest options to reach these goals while staying in alignment with the client’s truth about the area of practice and about herself.
  • Both educators and coaches assign tasks to their clients, but of a different type. The educator assigns tasks that will enhance a better understanding of the matter at hand and the expansion of knowledge.  The coach assigns tasks that will evoke better performance and functioning.

Looking at these practices, which one do you think is a better practice in order to invite the change in the field of childbirth?  Coaching makes so much sense when we acknowledge that individuals’ choices in childbirth are based on predetermined beliefs rather than on knowledge. Coaching is the art of helping others to adopt new concepts and perspectives in order to meet their desired goals. The new concepts will serve our clients better and will allow them to adopt new habits of behaving and responding. There are many predetermined beliefs, or myth, that can sabotage a healthy birth. Many of them are part of our collective unconscious, inherited from our ancestors through cellular memory – childbirth used to be a dangerous life experience!  Adopting new perspectives and patterns of behavior will allow both expectant parents and obstetricians to make better choices in childbirth.

If you want to learn how to integrate coaching strategies into your birth support practice, I invite you to join our Birth Support Coaching Course and bring on the change!

 

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