There is an over-arching view that those working in the field of medicine are a notch above the average person when, in fact, they are as infallible as any other human. The same flotsam and jetsam you see in other workplaces exist in medicine as well. There are those with ideological agendas, those with the tendency to make stuff up as they go along and those who deny responsibility for transgressions even when caught red-handed – sometimes especially when they are caught red-handed. There are adrenalin addicts, opinionated pontificators, manipulators, gossips, drama kings/queens, control freaks, bullies and eccentrics.
There are also those who display remarkable integrity and have a genuine desire to do right by their clients. There are many who are brilliant, skilled, decent and hard working.
Most people are some combination of both groups.
It would be nice if we could walk into any clinic or hospital and find the last group every time. That isn’t realistic. Women need to act as their own advocates. We need to do our research, find the best person for the job and not be afraid to walk out on the ones who are not suitable.
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Mar 04, 2009 09:16 PM
An OB's Birth Plan
by Poppy_Petal
Hello,
I've been a member here for a long time but don't post because I decided
nursing school with young children at home wasn't something I could personally
pull off. I'm 26 weeks with my 3rd (1st 2 were hospital births) and at my last
appointment my OB folding a piece of paper in
half and handed it to my husband. He told us it was information on hospital
policies and things and we could discuss at my next visit. All I saw was the
title Dr. ________ "Birth Plan" and I was amused because I know that
birth plans can be irrational and badly researched. After I read it I was less
amused and now plan on finding another care provider. I do believe the OB is a good doctor and I plan on sending a polite but
honest letter and I would also like to cite research in order to leave some
possibility that he will rethink his position. I am having trouble finding
research.
DR. ________ "BIRTH PLAN"
Dear Patient:
As your obstetrician, it is my goal and responsibility to ensure your safety and your baby's safety during your
pregnancy, delivery, and the postpartum period. My practice approach is to use
the latest advances in modern obstetrics. There is no doubt that modern
obstetrical advances have significantly decreased the incidence of maternal and
fetal complications. The following information should clarify my position and
is meant to address some commonly asked questions. Please review this
information carefully and let me know if you feel uncomfortable in any way with
my approach as outlined below.
* Home delivery, underwater delivery, and delivery in a dark room is not
allowed.
* I do not accept birth plans. Many birth plans conflict with approved modern
obstetrical techniques and guidelines. I follow the
I follow the guidelines of the American
College of Obstetrics and Gynecology
which is the organization responsible for
setting the standard of care in the United States. Certain
organizations, under the guise of "Natural Birth" promote practices
that are outdated and unsafe. You should notify me immediately, if you are
enrolled in courses that encourage a specific birth plan. Conflicts should be
resolved long before we approach your due date. Please note that I do not
accept the Bradley Birth Plan. You may ask my office staff for our list of
recommended childbirth classes.
* Doulas and labor coaches are allowed and will be treated like other visitors.
However, like other visitors, they may be asked to leave if their presence or
recommendations hinder my ability to monitor your labor or your baby's
well-being.
* IV access during labor is mandatory. Even though labor usually progresses
well, not too infrequently, emergencies arise suddenly, necessitating an
emergency c-section. The precious few minutes wasted trying to start an IV in
an emergency may be crucial to your and your baby's well being.
* Continuous monitoring of your baby's heart rate during the active phase
(usually when your cervix is dilated 4cm) is mandatory. This may be done using
external belts or if not adequate, by using internal monitors at my discretion.
This is the only way I can be sure that your baby is tolerating every contraction.
Labor positions that hinder my ability to continuously monitor your baby's
heart rate are not allowed.
* Rupture of
membranes may become helpful or necessary during your labor. The decision as whether and
when to perform this procedure is made at my discretion.
* Epidural anesthesia is optional and available at all times. The most recent
scientific data suggest that epidurals are safe and do not interfere with labor
in anyway even if administered very early in labor.
* I perform all vaginal deliveries on a standard labor and delivery bed. Your
legs will be positioned in the standard delivery stirrups. This is the most
comfortable position for you. It also provides maximum space in your pelvis,
minimizing the risk of trauma
to you and your baby during delivery.
* Episiotomy is a surgical incision made at the vaginal opening just before the
baby's head is delivered. I routinely perform other standard techniques such as
massage and stretching to decrease the need for episiotomies. However,
depending on the size of the baby's head and the degree of flexibility of the
vaginal tissue, an episiotomy may become necessary at my discretion to minimize
the risk of trauma to you and your baby.
* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this
procedure is not beneficial and can potentially be harmful to your baby.
* If your pregnancy is normal, it should not extend much beyond your due date.
The rate of maternal and fetal complications increases rapidly after 39 weeks.
For this reason, I recommend delivering your baby at around 39-40 weeks of
pregnancy. This may happen through spontaneous onset of labor or by inducing
labor. Contrary to many outdated beliefs, inducing labor, when done
appropriately and at the right time, is safe, and does not increase the amount
of pain or the risk of complications or the need for a c-section.
* Compared to the national average, I have a very low c-section rate. However,
a c-section may become necessary at any time during labor due to maternal or
fetal concerns. The decision as to whether and when to perform this procedure
is made at my discretion and it is not negotiable, especially when done for
fetal concerns.
rom RochesterRN-BSN
Mar 04, 2009, 09:57 PM
Re: An OB's Birth Plan
Sorry ....but I was a L&D nurse out of
school for a bit in a hospital that did 300+ deliveries a month. I hate to tell
you this...yes most doctors don't actually type this all out and call it a
birth plan and this is a bit weird...most talk about this stuff --to you and
your spouse/partner.........HOWEVER, that being said........I can't say as I
disagree with one single thing in this "plan". Yes it is blunt but it
is to the point. He is there for your and your babies best interest and I think
you took this in the wrong way. Especially if you liked him in person, if he
had good bedside manor. I hate to say this but this is how most docs practice
even if they don't put it into writing like this doc did. I might suggest that
you find a midwife. And honestly I am a huge believer that at home deliveries
are just stupid. I have seen bad things happen REALLY fast in what was EXPECTED
to be a totally normal and routine delivery. Times when if that delivery was
going on at home both mom and baby would have died!!! A matter of a few minutes
between --all is good and holy crap get into the OR NOW!!! We got about 10
seconds to get this baby out....I've seen a mom go into DIC and end up almost
dying and in the ICU for weeks afterward--totally unexpected. That is a HUGE
risk to deliver a home. Stupid if you ask me. As far as the Bradley method--
done by the book so to say this plan is a huge pain in the butt!! And my
biggest problem with it is that it tells not to have a baby getting the meds
that are standard to give on delivery-- The shot of Vit.K which is needed for
the baby to be able to clot his own blood--adults produce Vit. K in the
intestinal tract, by bacteria there...this does not happen right away in
babies. They should get Erythromycin ointment in the eyes to prevent infections
from causing blindness......this method tell parents not to allow these
meds......the other benefit the baby gets from the shot is that yes they cry a
bit...but in a brand new baby that is good, the crying helps them to clear
their lungs....I have seen babies that didn't cry at all until that shot, despite
many efforts and this was what got them crying to clear the lungs.....something
they have to do.
So despite the fact that this is a kind of inpersonal and blunt way to tell you
what he needs to be able to care for you the best way he knows how.......I
totally agree with everything. Sorry. Too many woman forget that childbirth is
serious and babies die and moms die when doctors are not allowed to do
everything they can to protect thier patients. OBs are suied a lot and if your
baby died you would be the first to sue if this stuff was not done.
And really things like being required to have an IV.....I always have though
this should be done. Its there if you need it in an emergency. No wasted time.
Your life and your babies are worth it.
I would have no problems working with him as a nurse
nor would I have any problems with him delivering my babies........of course if
he also had a good bedside manor. I would know that me and my baby were safe
and getting the best care possible. And BTW I have had 2 of my own and so this
is a mom speaking too!! lol -- I wis
I would have had an IV early --they blew mine 3 times in a row and then it was
too late to get my epidural.
I really think if you like this docs bedside manor and he seems nice you might
want to rethink this........he may be a really good doc. I worked with many
that were wonderful and the patients loved and yes they said these things a
little more nicely but most of them had the same ideas!!!
good luck and I hope all goes well with the delivery!!
I hope my honesty helps......
http://allnurses.com/ob-gyn-nursing/obs-birth-plan-375056.html
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Time to Reevaluate Cesarean Section Techniques
Thursday, May 10, 2007
Kenneth F. Trofatter, Jr., MD, PhD
The other day I attended a session entitled
“Myths and Truths of Cesarean Delivery Technique” presented by Dr.
Aviva Lee-Parritz from Boston
Medical Center.
The discussion critically evaluated the surgical techniques commonly employed
to accomplish cesarean deliveries. C/sections are one of the most common
procedures performed in this country (and probably the most common in women)
and becoming more common every day. The bottom line is that we all do them, but
the best approach to the operation has never been defined! When I
trained (too many years ago), the operative approach had been accepted for many
years and simply passed down from resident-to-resident. No one ever questioned
the legitimacy of that approach. After all, it was described in Williams’
Obstetrics and wasn’t that written by divine inspiration?!?
To be fair, the technique was based in good surgical principles designed to
minimize risks for bleeding and infection at a time when these were major
concerns, prior to both blood transfusion and antibiotics. Indeed, the
procedure most commonly used today (the low-transverse cesarean section –
referring to a cross-wise incision in the uterus, regardless of the skin
incision) has not changed much since it was first described by Kerr in 1926.
Over the years, we developed specific guidelines for the type of skin incision
(transverse, lower abdominal vs. vertical) that was made under specific
circumstances; we usually ‘developed the bladder flap’ (incised the thin layer of
peritoneum over the lower uterine segment and pushed the bladder down before
incising the uterus) except in dire emergencies; we knew the type of uterine
incision that was preferred (transverse or vertical) under specific
circumstances; we reached into the uterus to remove the placenta after the baby
was delivered and then wiped the uterine cavity clean; we closed the uterine
incision in two layers; and, then reapproximated ‘like-to-like’ (closed the
bladder flap, closed the peritoneum, closed the fascia, closed the subcutaneous
layer of fat, and then closed the skin) to complete the operation. And, despite
all those steps, most of us could perform the procedure in a woman having her
first one in less than 30 minutes ‘skin-to-skin’.
About 15 years ago, a paper was authored by Dr. John Hauth that suggested
closing the uterus in a single layer was just as good as closing in
two, thereby reducing operative time and the ‘perinatal morbidity’ associated
with prolonged procedures, mainly, blood loss, infection, and risk for deep
venous thrombosis and pulmonary embolism. In other words, there did not appear
to be any short-term risks to this approach and there might even be some
benefits. Around the same time, other papers challenged the necessity of
closing the peritoneum (the thin layer of ‘skin’ that lines the inner abdomen
and covers the internal organs (i.e., the ‘bladder flap’ over the uterine
incision as well as the peritoneum of the abdominal wall). Without critically
evaluating the individual risks and benefits of omitting these steps, many
practitioners jumped on the bandwagon of the ‘simplified cesarean section’ and
began closing the uterus in one big layer, leaving the raw surfaces of the
‘bladder flap’ and uterine incision exposed, and stopped closing the peritoneum
lining the inner abdominal wall. Although I was rather skeptical at the time
that this was really the right thing to do (raw surfaces tend to increase the
risk for adhesions (scar) formation), especially because we had no long term
follow-up on these women with regard to subsequent deliveries, our residents
loved it because there were fewer steps (although they never seemed to do the
operation any faster than us old fogies did in our heyday when ALL the steps
were performed), so we just sort of went along for the ride.
Well, in recent years, as the cesarean delivery rate has skyrocketed, vaginal
births after cesarean section have diminished (significantly), and we are
performing more and more repeat cesarean procedures (and threepeats, and
fourpeats, and fivepeats,….). We are also encountering more and more
complications secondary to the previous procedures (occult and overt uterine
ruptures, dense adhesions, placenta previas, placenta accretas, cesarean
hysterectomies…). It is becoming clear that revisiting what, why, and how we
are doing cesareans, and systematically ascertaining the best approach to the
entire operation is necessary. It is also likely that the approach I was
taught, based on what was considered to be ‘good surgical technique’ (but no
data) and passed on by tradition, and the current ‘minimalist’ procedure, also
based on a limited amount of data compared to the total number of procedures
done, are at opposite extremes and the ‘truth’ probably lies somewhere in
between.
As Dr. Lee-Parritz pointed out, if we look at the information already available
from various sources both in OB and other
surgical specialties, we are well on our way to defining a better approach to
cesarean section. Without going into details of the hows and whys, herein, her
analysis of the literature supports the fact that we should continue to use
prophylactic antibiotics perioperatively (probably best given prior to the skin
incision); we can probably perform most cesareans through a transverse
abdominal incision; we probably do not routinely need to develop extensively
the bladder flap; the uterine incision can safely be widened by blunt
dissection; the placenta should be removed by traction rather than by ‘manual
extraction’ (to minimize blood loss and infectious morbidity); the uterus
should probably be closed in two layers (at least for all women planning
another pregnancy, although how that is best accomplished and even what suture
should be used is yet to be decided; if no ‘bladder flap’ is developed, we probably
do not need to close either the visceral or parietal peritoneum; we should
reapproximate the subcutaneous tissues, especially in obese patients; and, we
can close the skin anyway we want to, although most patients would prefer not
to see sutures or have staples that need to be removed at a later time and,
actually, seem to have less postoperative pain when the skin is closed in a
running subcuticular (under the skin) stitch.
If these steps were routinely employed, we should be able to minimize short-term
risks of infection, bleeding, length of procedure, and perioperative pain and
perhaps put a dent in the long-term complications of uterine scar dehiscence
and pelvic adhesions that increase the morbidity of a subsequent pregnancy for
both mother and baby. Who knows, an improved technique might also reduce the
subsequent risk of placenta accreta and cesarean hysterectomy (allowing
women to have more and more cesarean sections!). Unanswered questions
could be readily addressed by a few well-organized multicenter research studies
(in view of the huge total number of cases being performed each year, both
first time and repeat procedures). We should be able to decide upon the best
technique for closure of the uterus, the best suture to use under specific circumstances,
and the best approach to employ with regard to closure of all the other body
layers we went through to get the baby delivered.
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