Tuesday, October 16, 2012

Baby III Week 23: As long as we're pointing fingers...

23 Weeks

Body stuff: It's getting fat. That's all you really need to know. My wideness in particular has been commented one THREE times this week.

Birth stuff: I had a prenatal appointment with my midwife this week. We went over my birth plan to make sure it wasn't too hardcore. I'm not trying to be an asshole or control freak in the delivery room... but my births are like my Super Bowls and every aspect is exciting and super important to me. It's not just about the end result, it's the whole experience, and I'm running through plays and little details because I love it, and I'm so stoked, and I'm so worried that my enthusiasm comes off as obsessive. Also, because in the past my "we prefer..." and "if possible..." requests were ignored, I definitely used stronger language just because I want it clear that I am an informed mother capable of being an active participant in the birth of my baby.

My midwife agreed it was a great tool for interviewing a potential OB to make sure my expectations matched both his practices and hospital protocol, but to cut it down some for the nurses on the birth day... and I agreed.

Wait... back up... potential OB? Yes, I've been considering straying from the CNM that I love, and the hospital that I also love, to birth in Monterey County. I know that I will probably have a wonderful experience at Dominican, but I know using an out of county hospital is a bit of a protest. You are a consumer when you are choosing a hospital. I don't like the service/product that Salinas Valley Memorial or Community Hospital of the Monterey Peninula provide and I will not give them my business even though, I know that because I'm prepared, I could have a good birth, I just may have to fight against policy. However, over and over I kept hearing about Natividad Medical Center... I always had this article, The Holistic Hole, in the back of my head. The OB's and nurses are working so hard (and the hospital is spending so much money) to provide evidence based care that is better for mothers and babies than what SVMH and CHOMP are providing (whose approaches are better for the staff/ hospital/ insurance co.). What kind of birth advocate would I be if I'm here calling out the hospitals to make these changes, but then I don't support them with my business? A bit of a hypocritical one.

In addition to my own personal conviction about where I was birthing, I also wanted to see if all the hype was true. I didn't like the idea of telling one of my students "I hear Natividad is the place to go," when I myself was not taking that advice. I much prefer being able to say "I've birthed here, here and here... this is what my experienced were."

So yesterday I had my appointment to have a consultation with Dr. Chandler, who practices in the hospital. I was shocked by how nice the hospital is. I didn't get a tour of the rooms, but everything else that I saw was as nice if not nicer than SVMH or CHOMP. The wait was long, but well worth it. When I walked in a passed a purposeful looking doctor that I just got a good vibe from, I kinda hoped that was Chandler. It was. He and a resident came in, unfortunately after an over hour long wait and the babies were on the brink of meltdowns.

If you've read a book on birth, you've probably read a list of questions that are suggested you ask a potential OB. I've never been a big fan of those lists, I tend to feel like the answer you want shows a little... like... "What is your c-section rate?" You are basically saying "I'm about to judge you on a number that is determined by about a bazillion factors that may or may not have to do with you as a caregiver... choose your answer wisely." Who isn't going to feel defensive? I put together a list, though most of these were just answered in conversation. I decided if we made it through this list and I didn't feel like the doctor was silently hating me, I'd pull out my birth plan.

Is it hospital policy to have an IV or hep-lock, can the mother waive either?

Does the hospital require a blood draw/bank?

Is it the hospital’s policy to requite continuous fetal monitoring? Are there telemetry devices available?

Is fasting during labor required?

Are there showers or tubs?

If my water breaks at home but contractions have not started, what are my options?

If the baby seems to be in distress with no other no other signs of complications, what actions do you take?

Who can I have in the room with me? Photography or video allowed?

If the baby is discovered to be breech, what options are available to me?

Can I deliver in an upright or semi-upright position?

Can I or my husband assist in catching?

How often do your patients require episiotomies?

When do you use forceps or a vacuum, do you require an episiotomy?

How do you manage the third stage?

Is delayed cord clamping an option if there are no complications?

If I require a c-section, do you manually dilate the cervix.

Of course I have personal feelings on all these points, but I tried to word questions so that whoever I'm interviewing wouldn't feel challenged, or blamed, like "how often do patients require episiotomies" vs "how often do you do episiotomies."

I made it to most of the questions and was super impressed. I never felt like Chandler was defensive or judgmental. Two doctors can say "you don't have to have continuous fetal monitoring" but one can make you feel like they are tempted to call CPS on you for it. I can sense a stifled eye roll!

I handed him my birth plan, prefacing that this wasn't what I planned to bring to the hospital, but that it would help me decide if I had found a good match. I said I wasn't trying to order spaghetti at Chinese food restaurant and I totally understand if these needs can't be accommodated here.

Here it is:

Gentry Family Birth Plan

Thank you for allowing us to summarize our wishes for the birth of our third child. We are experienced in birthing naturally, we believe this is the safest method for the mother and child. Thank you for helping us in achieving our goals.

Labor Wishes in Stage 1

·         IV Fluids – We do not consent to routine IV fluids. The mother experienced significant edema in her first delivery which complicated breastfeeding and caused considerable discomfort during the initial bonding time. The excess fluid in the blood stream can dilute oxytocin, slowing labor, dilutes the concentration of red blood cells potentially leading to anemia, decreased oxygen to the uterus and baby, and possible excessive bleeding in the third stage. If at any time fluids are necessary, please consult the parents before taking action.

·         Hep-Lock – We understand having a hep-lock in place is often standard procedure and that hemorrhage or dehydration can complicate getting vein access in an emergency. We still do not consent to having a hep-lock in place during labor and will sign a release if necessary. The mother suffers from vasovagal syncope and reflex anoxic seizures in response to needles and labor is not a time to be coping with either. IV’s have also caused considerable discomfort and bruising. We have successfully labored without a hep-lock in place.

·         Continuous Fetal Monitoring – We do not consent to continuous external or internal fetal monitoring; intermittent monitoring has been proven to be just as effective. The use of continuous fetal monitoring has shown an increase in instrument and surgical delivery without an improvement in fetal outcomes.

·         Fetal Distress – In the case of a nonreassuring pattern during intermittent EFM without other obvious signs of an emergency situation (excessive maternal bleeding, cord prolapse), we ask that a fetal scalp blood sampling is done before cesarean is considered.

·         Vaginal Exams – We prefer vaginal exams to be used minimally. If membranes have spontaneously ruptured before the mother has the urge to push, we may not consent to any vaginal exams to prevent the risk of infection in a prolonged labor.

·         Augmentation of Labor – We do not consent to the use of Pitocin in the first stage of labor. Pitocin causes the uterus to contract longer and stronger than natural oxytocin causing more pain for the mother and may deprive the baby of oxygen. Prolonged use can contribute to postpartum hemorrhage in the third stage. We are informed in natural methods to strengthen contractions, however we also respect the natural flow of labor which occasionally includes plateaus. We do not consent to active management of labor.

·         Artificial Rupture of Membranes – We do not consent to the artificial rupture of membranes. Amniotomy can increase instances of abnormal fetal heart patterns, some studies show that early amniotomy can increase cesarean rate by 20%, and vaginal exams after amniotomy can lead to maternal infection. Labor is less painful with intact membranes. If membranes remain intact in the pushing stage we ask they remain so until the birth of the baby’s head at which time the membrane can be removed.

·         Food and Liquids by Mouth The mother does not wish to have food/liquids by mouth restricted while in labor. We understand the reasons this is often hospital policy is to avoid aspiration if an emergency cesarean is necessary. However, fasting during labor does not guarantee an empty stomach or that the mother will not instead aspirate stomach acid. Fasting during labor can cause maternal ketone levels to rise, can cause unnecessary discomfort during labor and may negatively affect labor progress.

·         Pain Management – Please do not offer any form of epidural or narcotic pain relief during labor. Both pose serious risks that we are not comfortable taking during labor. The mother wishes to be able to move freely and have access to shower/tub if available.

·         Residents & Students – As long as they do not cause any unnecessary noise or distraction, we welcome residents & students to see a natural birth in progress.

·         Photography & Video – As long as is it does not interfere with the birth and there are no emergencies, we would like to have a close friend present to video tape and photograph the birth.

Labor Wishes in Stage 2

·         Pushing Positions – The mother would like to push in whatever position is most comfortable to her at the time. This mother’s experience has been that the lithotomy position increased the pain of contractions and made controlled breathing (and therefore pushing) more difficult. The lithotomy position can reduce blood flow to the baby, narrow the pelvis, and increase instances of tears. We will likely choose a semi-sit/squat position.

·         Mother Directed Pushing – The mother will push with urges.  Please do not count out loud for her, the father/coach has been trained to coach the mother’s breathing and pushing. Please offer us a mirror if available, and the mother would like to be reminded to touch the baby’s head at crowing if possible. She loved encouragement, but please no “get angry” or “push like bowel movement.”

·         Episiotomy – We do not consent to an episiotomy, which can increase instance of perineal injuries and blood loss. We would appreciate the birth attendant try perineal massage, support, oil and warm compresses to assist in the birth of a large baby. If a forceps or vacuum delivery is necessary we ask it’s done without an episiotomy.

·         Delivery – If the delivery is uncomplicated, the father may like to assist in catching the baby, we greatly appreciated this offer by the birth attendant in our previous hospital delivery. We do not know the sex of the baby, the father would like to announce it.

Labor Wishes in Stage 3

·         Immediately Following Birth – We want our baby placed on the mother’s chest for skin to skin contact, even before the cord is cut. Any routine evaluations can be done on the mother or be delayed. If complications prevent the mother from having skin to skin with baby we ask the father takes the baby for skin to skin instead.

·       The Umbilical Cord – Please do not clamp the cord until the cord has stopped pulsing. Delayed cord clamping has positive effects on fetal iron stores, total red blood cell volume, and postpartum fetal blood pressure. The father would like to cut it.

·         Breastfeeding – The mother wishes to nurse her baby immediately. Breastfeeding stimulates oxytocin production which is aid in the delivery in the placenta and stop postpartum bleeding.

·         The Placenta – We do not want the placenta, but we would like to see it and take pictures of it.

Newborn Care

·         Rooming – We would like a private room. We want all medical procedures done at bedside. If our baby does need to be taken away for any reason, one or both of us would like to accompany him. We want our hospital stay to be as short as possible.

·         Eye Ointment – We would like eye ointment to not be applied until the end of the first hour after birth. We want erythromycin to be used, not silver nitrate.

·         Bottles & Pacifiers Please do not offer any bottles to the baby without parents' notification of a medical need. No pacifiers or artificial nipples please.

·         First Bath – We do not want our baby bathed.

·         Circumcision – If we have a son we will not be circumcising him.

Thank you for taking the time to help us achieve a natural childbirth for our third baby!

It went so well. Only issues, apparently fetal scalp blood sampling isn't really done anymore... so once again I made myself look a little dumb by having old information. Totally not as bad as the enema encounter at SVMH though. Also, they don't like video of the actual birth, like SVMH. I think we can work with that, but I will be bringing it up again because I really want that moment that we find out if we have a little boy or girl recorded.

I hope this wasn't all too good to be true, because honestly so many of his comments were shockingly fantastic. He asked if I had a doula and when I said no said "we really like our mothers to have doulas, but it shouldn't be a problem, you sound well prepared." He was totally fine with me delivering in whatever position I wanted (ie, not on my back). He mentioned having wanted to attend the recent Midwives Alliance of North America conference that I went to and that he recently watched and loved The Business of Being Born. Part of me wondered if he was reading from the "in case of natural mama" script... but with so many people saying to many wonderful things, I think this may be the real deal.

So, I think I'm sold. I still need to tour the hospital, but I feel really good about all this.

Here's my 23 week pic, all ready to go celebrate 5 years of marriage with Eric



Baby is grapefruit... or giant onion sized.

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