Just say No!
January 22, 2015 8:12 AM   Subscribe

Expecting #2 this summer! Help me rock my NUVBAC in a hospital. Teach me the magical 'No' phrases that won't tick off the medical staff but allow me to have the birth I want (emergencies/ extenuating circumstances aside).

Our 1st ended up being a c section due to pre e and an unfavorable cervix. If you want to you can read my previous question here. I am doing everything I can to avoid pre e this time.
We moved and have a new doc and will be delivering at a new hospital. Our dr is super supportive. He will let me go to 42 weeks before talking interventions. The hospital has wireless monitoring, I will be free to do as I please during labor. All sounds awesome right?
Well he may not be on call when go time comes and I have heard not so great things about the other Dr's who deliver there. One 'just doesn't do' VBACS. Some of the nurses are awesome and some tell you that you are going to kill your baby doing this (seriously, she said this to a friend who rocked her VBAC).
I do not want a hep lock. I will fight tooth and nail against it. I want to be left alone, I don't want continuous fetal monitoring, I want the freedom to use the birthing tubs and showers as needed, I want to change positions and actually birth however feels comfortable. I will have a birth plan, but I obviously don't want to word it so negatively.
Here's the thing, I am not as rigid as I sound. I understand that emergencies happen and births don't always go the way you want. My first birth was planned for a birth center but when I got pre e I was sent to the hospital. I was willing to change my total plan for the safety of myself and my baby, I just don't want them to see that flexibility right away and push me toward interventions that I don't need.
I'm willing to guess that they will tell me certain things are 'hospital policy' like the hep lock or continuous fetal monitoring, but there is no solid evidence that backs up either of those being necessary. I don't want to be treated like a disaster waiting to happen or scared in to something because I'm too tired to fight anymore, you know?
How do I just say I understand the risks but no thank you and stop asking please. Does that actually work? Can I get my Dr to put his signature on my birth plan or put it in my chart that he supports my choices so don't bother pushing me?
posted by MayNicholas to Grab Bag (31 answers total) 1 user marked this as a favorite
Can you write down what you want now and give it to your husband or whoever is going to be there with you and go over it with them so they can co-advocate for you if you are, you know, focused on other things at the moment a question is being asked?
posted by WeekendJen at 8:18 AM on January 22, 2015 [3 favorites]

What does your doctor suggest? I think that's the most important thing. If he believes strongly that you should be allowed to try a VBAC, can he put a note in your chart?
posted by roomthreeseventeen at 8:24 AM on January 22, 2015 [2 favorites]

Can you hire a doula? Many have experience helping parents stay on track with birth plans.
posted by ThePinkSuperhero at 8:25 AM on January 22, 2015 [23 favorites]

My daughter just delivered her second child by VBAC. She had pre-eclampsia with her first, an uncooperative cervix and the inevitable C-section. It may cheer you to hear that pre-eclampsia occurs much more often with first babies - I didn't know that. It rarely happens twice. She had no problem with protein or blood pressure with her second, so that fortunately was not an issue.

She was firm about her desire for VBAC, though her OB was not so supportive, which makes me crazy to contemplate! At the birthing center, when her BP was normal and the cervix was favorable, she was able to labor as she wished, with a midwife for the birth, and this was at a huge medical research hospital that delivers 5000 babies a year. My daughter raved about the midwife, who cheered her on with "You're a rock star!!" cheers after contractions. Of course, if an emergency had occurred the OR was available, but instead she had the low-tech VBAC she wanted.
posted by citygirl at 8:27 AM on January 22, 2015 [1 favorite]

We moved and have a new doc and will be delivering at a new hospital.

Some US hospitals (such as my local one) have a blanket policy against all VBACs, full stop, where suddenly even the cool doctors who want to attempt them cannot. Make sure this is not the case at your new hospital. Hospital policies can also suddenly change -- seek out the gossip on this question and be prepared to adapt your plans accordingly.

Agree with ThePinkSuperhero that hiring a Doula is pretty much the tried and true way of avoiding intervention. Best wishes for a good birth!
posted by hush at 8:41 AM on January 22, 2015

Best answer: Hire a fabulous doula who has worked this hospital before and let her run interference for you; you have other things to be doing (like breathing, tubbing, yoga ball bouncing and being left alone to do your thing.) Screen potential doulas specifically for this task.

Get a doula, get a doula, get a doula if you possibly can.
posted by DarlingBri at 8:42 AM on January 22, 2015 [5 favorites]

Best answer: Yes, you must hire a very experienced doula that knows all of the staff at the hospital. Find the most experienced one you can. No new doulas.
posted by littlewater at 8:44 AM on January 22, 2015 [2 favorites]

A birth center which doesn't have interventions available is your absolute best chance of avoiding interventions, because they're not going to even offer them unless you absolutely need them and require transfer to the hospital. If delivering at a birth center with a midwife is off the table, I agree that your best chance for a successful NUVBAC is with an experienced doula who is familiar with the hospital's staff and policies.
posted by rabbitrabbit at 8:50 AM on January 22, 2015 [1 favorite]

At some hospitals you can put together a written birth plan and discuss it with the hospital in advance. You write up what you want, bring it to the hospital and discuss it with them and make sure they can abide by it. You could probably get help doing this from a local doula or childbirth educator.
posted by alms at 8:55 AM on January 22, 2015

I had pre-E and breech with my first and ended up with a somewhat emergent c-section. The second was a VBAC. They were fairly strong about me having an epidural though, in case something did not go well, they wanted to be able to move to surgery quickly. This was in part due to the fact that they anticipated a difficult time getting an epidural/spinal in due to my anatomy and past history and did not want to have to deal with that in an emergency. I did not have my OB, but the one on call and I felt really no pressure at all for interventions. I think if you are at a hospital and OB practice that supports VBACs you are likely to be successful.
posted by sulaine at 8:57 AM on January 22, 2015

This is exactly what doulas do. Find the best one you possibly can.
posted by Metroid Baby at 9:11 AM on January 22, 2015

Best answer: Nthing hiring a doula. You can also read up on issues of informed consent and ethics in obstetrics (see, e.g., this). Read up on any relevant law or hospital policies regarding maternal-fetal conflict, override of patient refusal to consent, etc. Make sure your birth partner has authority to act as your health care proxy or attorney-in-fact (language differs state-to-state) -- have copies of that documentation with you. Use specific language like "I do not consent to administration of an epidural" rather than "my preference is for an unmedicated birth."
posted by melissasaurus at 9:18 AM on January 22, 2015 [2 favorites]

My doula was awesome. One thing she said several times during my birth, when someone came in and said it was time for Intervention X, was "tchemgrrl is not ready for that just yet. Can we see if we feel differently about it in 30 minutes?" I thought it drew a nice line of setting a boundary without cutting an option off entirely.
posted by tchemgrrl at 9:30 AM on January 22, 2015 [4 favorites]

Hire a doula. I would also really sit down with the doula and go through every likely possibility and discuss what interventions you would be comfortable with in each situation.
posted by betsybetsy at 9:43 AM on January 22, 2015

You hear a lot about the "spiral of interventions" and that getting a hep lock or fetal monitoring is just opening the door to a c-section, but in my experience, that wasn't really true. I'd also hoped to avoid any of this, but eventually needed both a hep lock and fetal monitoring along the way, precisely to keep me on the path to avoiding a c-section, which I did. Every situation is different, but I think there's a way to approach things with your team that both honors your desire to avoid interventions at all and also recognizes that some intervention may be necessary to get you to your ultimate goal of VBAC.
posted by judith at 10:11 AM on January 22, 2015 [3 favorites]

Best answer: I'm going to n-th everyone that says getting a doula is likely to be helpful, and that specifically you want to look for a doula who has done a significant number of births at the hospital you'll be delivering at, since that means she'll have a good handle on which nurses are supportive of things like TOLAC/VBAC and which are not. Also, I'd recommend either screening for or negotiating with your doula an agreement that she will show up when you first go to the hospital, regardless of where you are in your labor. My doula is hands-down the reason I was able to avoid pitocin and potentially a host of other interventions when my water broke and contractions didn't immediately start--and the one thing that I really regret was the amount of stress I had around the fact that our contract specified she would show up once I was "in active labor", but I ended up in the hospital well in advance of that stage. (She did show up shortly after I went to the hospital, so it was all fine, I just wish I had been able to rely on that in advance rather than wondering whether she'd offer to come early.)

Knowing when your doula will show up in-person and having that align with when you think you'll need her support most is essential. My doula was *most* helpful in navigating my options and helping me talk to my OB and the nurses before labor started, and played a pretty minor role once I was in active labor. (Part of the reason she was so effective is because she was a fairly medically-oriented doula, does not attend births outside of the hospital, was specifically okay with doula-ing for women who wanted epidurals or were having planned c-sections--so she had a very good reputation among hospital staff, and it made it so the nurses were going the extra mile to also help me negotiate with my OB around intervention timing.)

The other thing I'd note is that the actual hospital you choose to deliver at may be as important as your choice of OBs. My local hospital is extremely VBAC-friendly and gets women from neighboring communities who have closer, less-friendly options. The more "crunchy" orientation of the hospital (they are certified Baby-Friendly and in addition to VBAC, have lots of support for women who want to deliver without epidurals and that sort of thing) meant that the nurses had a lot of experience seeing successful examples of VBAC and un-medicated labor and all that stuff, which meant that when my OB and I were having a stressful conversation about induction, it was actually the nurse in the room who piped up and said something about a breast pump being available to try and start contractions, and who went and found and printed out the information about how frequently and how long to use the pump to try to start labor. Later, the nurse was very pro-active about watching for the second that my OB went off-duty and finding the OB on-call and knowing how to phrase things to get her to sign off on removing the continuous monitoring and in favor of intermittent Doppler monitoring instead.

A lot of the success I had in avoiding interventions didn't have anything to do with what was in my birth plan, it was help from women (the doula, the nurses) who had seen women in my situation and were able to provide me with options I didn't know were available, and which my OB was not terribly forthcoming with (but was okay with doing once I requested it).
posted by iminurmefi at 11:16 AM on January 22, 2015 [1 favorite]

Well...hire a good doula. Mine wasn't really any use to me at all. She was too inexperienced.

Hire, if you can, one that has done VBACs at this hospital before. Then she is more likely to be fully prepared, and to prepare you.

Know about EMTALA and your rights not to be treated (which includes hep locks and so on) or have surgery done to you without your consent. Make sure your husband is briefed on these things also. Be prepared to be unpleasant about it, if you have to.

Do you know the c-sec rate at your hospital? You might be able to find out here.

Prepare for the worse, hope for the best.

And congratulations!
posted by emjaybee at 11:18 AM on January 22, 2015

Doula, doula, doula....

Experienced who's worked that hospital before.
posted by jrobin276 at 11:46 AM on January 22, 2015

Best answer: Agree with the suggestions of a doula. These questions regarding informed consent might be helpful to print out, too.
posted by PhoBWanKenobi at 11:47 AM on January 22, 2015

Best answer: As a doula, one of the most useful delay tactics I have when a practitioner offers an intervention is to ask: what happens if we wait? In most non-emergent circumstances, you do not have to make a decision right away. Ask for time. That gives you and your spouse an opportunity to discuss what you want to do, and think about how to respond. "I'd like to work through a couple more contractions and then see how I feel." "Let me see how I'm doing after I walk around a bit." Etc.
posted by linettasky at 1:03 PM on January 22, 2015 [1 favorite]

If possible, ask for copies of the hospital policies. I couldn't imagine a nursing supervisor would have an issue showing you the procedure that covers the policies for when they do certain tests. Heck, maybe your super awesome doctor can get them for you in advance. (Don't ask a nurse, get a nursing supervisor)

This way, if the worse happens and your awesome doctor can't do your delivery, you have the policies at your finger tips to help fight against that "it's the rules, and no i swear i didn't just make that up!" feeling.
posted by Suffocating Kitty at 1:14 PM on January 22, 2015

A doula that has worked at that hospital before, as everyone says, but also you might ask your doctor for a rec for a doula he likes working with. A lot of people set up the doula/doctor relationship as adversarial, but I feel like it needn't be. Of course you should still interview the doula and so forth, but it can be a good starting point.
posted by freezer cake at 2:43 PM on January 22, 2015 [1 favorite]

Tour the hospital and ask the nurse who does the tour for doula recommendations.
posted by internet fraud detective squad, station number 9 at 3:17 PM on January 22, 2015

Best answer: L&D nurse here. Let me start off by saying that I agree completely with everything you're saying about VBAC. You're absolutely correct that the overall risk of VBAC is very small and that things like continuous fetal monitoring and routine saline lock placement aren't evidence based. It sounds like you have made an informed decision about the risk of VBAC, that you understand the rationale for routine saline lock placement during a trial of labor, that you understand the rationale for continuous fetal monitoring during a trial of labor, and have decided you are comfortable with that level of risk and with disagreeing with those rationales.

I fully believe that you are the boss of your body and your birth experience. No one gets to do something to your body without your consent.

With all that said... I have to wonder why you're planning to give birth in a hospital at all. Continuous fetal monitoring and saline lock placement will be part of the written VBAC policy at every Joint Commission accredited hospital in this country. You are free to disagree with the philosophies behind that (I sure do!) and you are free to decline interventions as you see fit (thumbs up!), but you should be aware that by choosing to give birth in a hospital, you are setting yourself up for a very acrimonious experience. Even the most sympathetic nurse (hi!) is required to practice according to the policies and procedures of the hospital that employs her if she wants to keep her job, and even the best doula is not qualified to give medical advice.

Is there are a reason you aren't planning to give birth at home?
posted by jesourie at 3:43 PM on January 22, 2015 [7 favorites]

Came here to say doula and/or stay home.

The crappy thing about a practice where some of the doctors don't "do" VBACs, is that if you show up in labor and your doctor isn't on call, you're usually out of luck. Have you asked your doc what happens then?

But yeah, stay home and rock it out.
posted by checkitnice at 3:49 PM on January 22, 2015

Just came in to say DOULA!
posted by rubster at 4:21 PM on January 22, 2015

The risks of home birth are lowest for women who have already had one vaginal birth and haven't had a c-section. When people talk about home birth being as safe as hospital birth--and that is still an open question--they are not talking about this scenario. That doesn't mean you can't weigh the risks against your desire to avoid certain things in the hospital.

The other issue with giving birth at home is that in a number of states, there is no such thing as a certified nurse midwife who attends home births. If that is the case, your birth attendant will likely lack the training necessary to deal with an emergency situation, and will certainly not have privileges at a local hospital. This has the effect of greatly complicating the transfer process and extending the time it takes for you to get emergency care. It also means the doctors involved won't have your medical information, nor will you know them. If you're in a place with CNMs who do homebirths, you're in luck--ask about how they handle transfers and about their relationship with the closest hospital (one reason I didn't birth at home was that the closest hospital to my home was not very good). You should consider what you will do if you want to transfer and the midwife resists or disagrees. You should also ask about what conditions would cause you to "risk out" of home birth and if so, how you would get ongoing care. You want a somewhat risk-averse midwife because backup is a (relatively) long way away. Free-standing birth centers are not significantly different from your home in many cases, and strike me as a bit silly unless you live very far from a hospital and the birth center is close to a hospital.

Good luck!
posted by internet fraud detective squad, station number 9 at 6:34 PM on January 22, 2015 [1 favorite]

Response by poster: Already planning to hire a doula. Home birth is not an option for us. Neither my husband nor myself would feel comfortable. The closest birth center is about 45 minutes away and in a very rural area so not close enough to a hospital for a quick transfer. I just feel that just because we are choosing a hospital birth for the 'just in case' scenarios, we should not be treated as though the 'just in case' is the inevitable.
Thank you all for the info! Fingers crossed we find the perfect doula and there is nothing but smooth sailing!
posted by MayNicholas at 6:48 PM on January 22, 2015 [4 favorites]

In your birth plan, could you write that you decline hep locks and continuous monitoring and request that they not ask? I know people often request a lack of speech re: meds -- "don't offer pain medications."

I agree that the hospital matters. I know someone who avoided a c-section that her doula and midwife (!) were ready to encourage, because the ob on duty said "why don't we monitor for one more hour and then decide?" He did this because the hospital was trying to reduce its c-section rates.

Also, the nurses are crucial. So as shift change approaches, you might have your buddy tell the nurse how great she or he has been and ask that she please help you get a nurse next shift who can help with the natural approach. Maybe a nurse can comment on the idea, but my sense was that the nurses were talking between shifts and that some preferentially picked the natural births.
posted by slidell at 7:40 PM on January 22, 2015

With regard to the fetal monitoring and IVs, I wanted to mention that although I think jesourie is probably correct that they will be hospital policy in your situation and you won't be allowed to decline them, they may not prevent you from having the freedom you are looking for.

I was also pro-natural birth with my first delivery, and was attended by a midwife at a hospital known for being low on interventions and supportive of natural labor. But a couple of days after my due date, my amniotic fluid was so low that they had to induce for baby's safety. Because of the Pitocin, I was required to have fetal monitoring and IV, but they had portable, waterproof devices for this that were not connected to any machines. I had to roll the IV bag around on a stand with me, but I was still able to use the shower/tub, walk, and get into whatever position I wanted. The nurses and midwife left me alone for the most part. It was a little more awkward than it would have been without these things, but all told, it was not the hardest thing I was dealing with. I suggest you look into the availability of these types of devices at whatever hospital you choose if you think that might be an acceptable compromise.
posted by zadermatermorts at 7:18 AM on January 23, 2015 [1 favorite]

So, here's the thing. You are making a choice to seek care at the hospital despite other options available to you, presumably because you believe the hospital and its medical professionals have something of value to offer you. You might consider the ways in which it's not entirely fair to expect full access to those services solely for your peace of mind, not out of any necessity, without being willing to respect the policies and procedures that accompany those services.
posted by jesourie at 6:14 PM on January 23, 2015 [3 favorites]

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