Monday, May 26, 2014

Birth Abuse is Real - A Call for Reform in the Hospital Setting

The amount of abuse that happens in the birth world is quite appalling. As a birth doula, I have witnessed comments from nurses and doctors that are quite unsettling. I have also reached out to my doula community and was even more shocked with what other doulas have experienced while supporting laboring women in the hospital. 

Here are some real comments made by OBs, nurses and other support people in the hospital setting:

"We are going to move you into the OR when it is time for you to push, this will make it easier on us when your uterus ruptures, so your baby won't die". - to a VBAC (vaginal birth after cesarean) mom

I'd like to discuss some of the research about vaginal birth after cesarean and uterine rupture. 

In this study, they examined the risk of uterine rupture in women who had had a previous c-section. They found the risk for uterine rupture was 0.3% (based on 1,922 women).

Also, this study found that uterine rupture occurred in 1.3% of their patients going for a VBAC, and that "uterine rupture was associated with the use of epidural analgesia."

If you average these two studies out, the risk of uterine rupture after a previous cesarean was 0.8%. Women are bullied every day into repeat cesareans by nurses, doctors, and even friends and family. This is not good evidence based medicine. As you can see from the above statement, this comment was unacceptable and wrong. 

In my experience, many doctors and nurses act like a cesarean is much safer for the mother and baby than a vaginal delivery. I have even experienced a doctor laugh about the possible side-effects listed on the consent form to a woman prior to a cesarean, expressing that they rarely happen (and then the most severe complication actually happened to this person). C-sections do have their own risks. 

This study concluded that delivery via C-section was related to a longer length of hospital stay in late pre-term babies.This study concluded that cesarean delivery "increased the chances of unfavorable neonatal outcomes."

Cesareans also have other risks, including: increased risk of bleeding, longer healing time compared to a vaginal birth, breathing problems in babies, increased risk of injury to your bowel or bladder, wound infection and more. 


"At my very first birth as a doula, the mom was shaking while in transition (no epidural) and the monitor kept slipping. the nurse came in and very rudely kept repeating "STOP SHAKING" to the mom, who obviously couldn't help it."


A nurse who works with birth every day should know that involuntary/uncontrollable shaking is a totally normal part of labor. If you have ever seen or experienced this shaking, you know that it cannot be controlled or stopped. Additionally, transition is a time during which women feel very sensitive to suggestions or comments. I'd like to propose that these kinds of people should not be working with women who are in such an intimate and vulnerable experience.


"To a mom in the NICU with her 1 day old: you better not make him work too much to eat (mom wanted to breastfeed), Formula will be much better because then the baby won't get too tired while eating."

There are so many studies out there that conclude that premature babies should only be fed breast milk, be it from the breast or a cup (if the breast isn't available). There are so many things wrong with the comment above. First, formula should be a last resort to a premature baby. Mom's breast milk is the best, and if that's not available, then the preterm baby should eat donated breast milk from a milk bank, if available. The International Breastfeeding Center states the following:


Work in NICU’s friendly to breastfeeding, especially in Sweden, have shown that babies can start taking the breast even by 28 weeks gestation and many are able to latch on and drink milk from the breast by 30 weeks gestation. Indeed, some babies have gotten to full breastfeeding by 32 weeks gestation. This means breastfeeding, not receiving breast milk in a bottle or tube in the stomach. With Kangaroo Mother Care and early access to the breast, it can be done elsewhere as well. 
This study also shows that the use of exclusive breast milk (no formula) to extremely preterm infants in the NICU is the best.  

"I overheard an OB say, "You are not really in labor, We need to start pitocin or you never will be" to a mom who was 4cms and was in the middle of a contraction"

Do you know that stress and fear contribute to "failure to progress" in labor? When an animal goes into labor, they find a quiet and private space to birth their babies. If they feel threatened or disturbed, they begin releasing stress hormone, and it shuts down their labor until they find an undisturbed space. The same goes for women in labor - if they do not feel safe or protected, they begin to release stress hormones and labor will slow down or stop. Think about the hospital environment for one moment - the woman is meeting nurses and possibly the doctor for the first time, people are coming in and out of her room, support personnel are talking to her during her contractions, she is strapped to a fetal monitor and sometimes forced to lie in a position that is excruciatingly painful for her... this scenario often leaves the woman feeling the opposite of safe or protected. 

It's quite shocking that so many people deny this emotional and hormonal aspect of childbirth. Every doctor knows that when stress hormones are released during any other time, the body is in fight-or-flight mode and many other functions (like digestion) shut down until the person feels safe and at ease again. How is childbirth any different?

"Your baby doesn't know how to nurse. You have to teach him (as the nurse forcefully put the baby on the breast, and opened its mouth with her finger)."

This isn't necessarily abuse, but it is ignorance at its finest. Many babies are born as nursing machines! They immediately latch on and know exactly what to do. Every baby, including animal babies, has the innate instinct of how to feed themselves. Breastfeeding can be difficult if you don't have the right latch (which usually takes only a couple of adjustments), but babies certainly know how to do it.

As a side note, babies who were born to mothers with an epidural may be slower to feed, or have more problems nursing (although not always the case). This study found that "intrapartum analgesia was associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week." 


Scare Tactics During Childbirth

Some situations are real emergencies. I get that. But many doctors use scare tactics in situations where they aren't warranted (which causes the release of stress hormones in laboring women, and we all know what happens next). This can lead to depression and post-traumatic-stress-disorder in women who had a less than ideal birth situation. If it was a true medical emergency, the woman is already feeling scared and traumatized - it's not necessary to throw the "your baby is going to die" card in her face. Here are some real examples of what doulas and mothers have experienced:

"The OB called for a c-section, and mom asked for monitors to be repositioned as she could still feel baby moving vigorously inside her. The ob nearly bellowed, "By all means, argue with me while your baby dies!" This was after the mom had already been bullied into every intervention, and it seemed clear the OB wanted to give the mom a c-section from the beginning."


"Had an OB point his finger in a mom's face while was screaming at him to shut up during contractions, he growled at her that she was in "his house" and he would talk to her when HE wanted and he wasn't on her schedule. It was one of my first births and I spoke out of turn, tried to quietly say "Dr I think she's in a lot of pain right now, if you can just wait until the break between contractions..." never got any further because he turned and pushed his finger in MY face and told ME to shut up because I didn't know anything and didn't need to be there. I was then asked to leave for almost 2 hours while the epidural was placed (it didn't take 2h, OB was being punitive)."

I'm wondering if doctors like this actually like delivering babies. Doctors can be tired, but honestly? 


"My OB told me that I was putting my baby at risk by hiring a doula to support me throughout labor. Needless to say, I switched providers (even though I was late in my pregnancy) and had a great birth experience." 

Research clearly shows that having a doula as a member of the birth team decreases the overall cesarean rate by 50%, the length of the labor by 25%, the use of oxytocin by 40% and requests for an epidural by 60%.*

Additionally, in the article Safe Prevention of the Primary Cesarean Deliverythe American Congress of Obstetricians and Gynocologists states that: 
Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery (**). Given that there are no associated measurable harms, this resource is probably underutilized.
"I saw an OB threaten to call the cops & have the mom "baker acted" if she wouldn't be induced (baby looked perfectly fine on the monitors)."

Do you remember what I said about stress hormones above? Talk about a labor stalled because of of an abusive doctor...

For those who don't know what the Baker Act is, this explains it: 
The Baker Act allows for a person to be picked up and transported to a crisis stabilization unit for an involuntary psychiatric examination. It is based on the behavioral criteria that the person may be harmful to himself or others. If the person meets these criteria, the judge signs the Emergency Admission Order prepared by the Clerk.
"According to the ultrasound, your baby is big and you will probably need a C-section"

This baby ended up weighing just over 7 pounds at birth. I have heard this countless times, and in my experience, the estimation is often inaccurate. This study concluded that "all ultrasound estimated fetal weight formulae would either over or under estimate the fetal weight." 


OH THE NERVE!

The following are crazy comments made by medical professionals. I don't think they need much explanation.

"A nurse to my client (who was being cared for by social services) after having baby #3 said that maybe she should keep her "legs crossed or get the tubes tied"!!! I could have strangled this woman for making her feel bad about her situation! She had no idea about her history, or the hardships she had been through!"

"While walking the halls with a VBAC client, there was a very loud conversation at the nurse's station making fun of a woman's birth plan. Particularly her request for immediate skin-to-skin in the event of a cesarean. It angered and shocked both my client and I."

Come on... we all know the benefits of skin-to-skin. If you don't, read here. This article also points out the importance of skin-to-skin following a cesarean. 

"As a doctor yanked the placenta out before it had separated, my client was screaming in pain. He said in a sarcastic voice, "Get a grip.""

"As on the on call doctor was sewing me up from a repeat c-section (my doctor wouldn't give me vbac options), she said, "yup you weren't pushing that one out.""

Doctor to doula: "You need to press right here (points to two spots on back)." 
Doula: "She really doesn't want to be touched right now - it's making her contractions more painful, and she's handling her labor so beautifully."

Doctor: "But the key is to press and make pain somewhere else so she will be distracted from her contractions."

"Mama wanted to natural birth - she was induced at 39 weeks and after 4 vaginal checks in 10 hours (doc was in the room to do another vaginal check) the doc said, "if I can't get these two fingers up there how do you expect the head of the baby to come out from here!""

Stress can also cause tension. Increased tension = difficult vaginal exams. 

"I had an OB tell me that I had to be in bed, on my back, and on monitors while attempting a natural childbirth...."because we need to know ahead of time if it is a bad baby.""


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Folks, abuse in childbirth is real. It happens all the time and, unfortunately, nobody says or does anything about it. If you experience it or witness it, there are actions you can take. Contact the hospital ombudsman and report the doctor or nurse. If it's a nurse, contact the nurse manager of the unit. We should really be taking steps to correct this - verbal abuse and bullying is uncalled for and should be taken seriously. 


A Call For Hospital Birth Center Reform

Birth trauma is also real. Most of the doctors and nurses, who made the above statements, or something similar, do not see their patients after they have given birth. They don't see the trauma they may have caused her. They don't see the postpartum depression that she is experiencing because she hasn't come to terms with her birth experience. They don't experience the post-traumatic stress disorder that she developed from a traumatic birth. Woman are human beings, capable of emotion and hurt. 

This system must be changed. Doctors and nurses should be respectful and kind, promoting a safe and protected environment. This article, in the Journal of Perinatal Education, about health-care reform for pregnant and laboring women, states:

Health-care reform must promote, support, and protect natural, safe, and healthy childbirth. Because most childbearing women and their newborns are healthy and at low risk for complications, it is important that women have access to appropriate quality health care in a safe environment that supports a woman's innate ability to give birth, breastfeed, and begin to mother her newborn. In such an environment, overuse of costly interventions that interfere with the normal process of labor and birth are avoided except in the rare situations in which women are at high risk for serious health problems.
In Conclusion

I'm certainly not saying that all nurses and doctors are bad. I've had the pleasure to work with some of the most caring and wonderful health care professionals. Those support people are a beacon of light for women during their birth. But, abuse happens and we should do something about it. No woman deserves to be verbally abused and bullied while she is experiencing one of the most powerful and intimate experiences of her life. 


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**Klaus, M., Kennell, J., Klaus, P. Mothering the Mother.: Addison-Wesley Publishing Company, 1993.