Talk It Out - Part 3

This post is for Kimberly, who requested I write a follow up post to Talk It Out, with examples of positive communication and what to look for when talking with your provider about your wishes. Part 2 can be found just prior to this post.

When talking with your provider, there are key tip-offs that your provider is not as supportive of you, the consumer, as you might like. The following terms can tip you off that your provider doesn't respect or recognize your autonomy, or your patient rights.

• "I/we don't normally let..." normally used in conjuncture with such terms as 'a woman labor more than 24 hours', 'a woman push on all-fours', etc...
• "I/we can't let..." normally used in conjuncture with such terms as 'you wear your own clothes', ''only have a hep-lock', 'you eat or drink', etc...
• "We don't do..." normally used in conjuncture with such terms as 'delayed clamping and cutting of the cord', 'squatting births', 'intermittent monitoring', etc...
• "I/we require..." normally used in conjuncture with such terms as 'a minimum 4 hours in the nursery', 'nursing every 2 hours', 'mom push on her back', etc...
• "This is how we will..." normally used in conjuncture with such terms as 'proceed with your care', 'treat your ______', etc..
• "You will be..." normally used in conjuncture with such terms as 'hooked up to a fetal monitor', 'given pitocin', etc...
• "You need to... " normally used in conjuncture with such terms as 'trust me/my decision', 'have _____ procedure', 'labor/birth like this (i.e. lie on your back, put your feet here, open your legs this way, relax, stop making noise, etc...)', etc...

If you only get this far in the post and you say 'my provider says that stuff', you might not need to read any further to know that you should consider changing providers.

If you have already started these types of conversations with your doctor and they are either able to clarify, to your comfort, their reasons or meaning, or if you have not heard your provider utter these types of terms, you might have found a good provider. :)

Positive communication with your provider has 4 main intents/purposes:

• To keep your relationship with your provider positive
• To give you full information so that you can make a full and informed choice
• To facilitate more/open communication with them in the future
• To keep you in the position of control - this one sounds harsh, but, remember, YOU are responsible for your health care. You are in control of your health care decisions, and, trust me, you don't want to give that power to anyone else

Now that we know what tips us off, ahead of time, to a provider that isn't supportive of mom and her autonomy, and we know what our goals of positive communication are, let's talk about how to get that communication going prenatally.

Even if you don't plan on having a formally written birth plan, it is a good idea to write down, for your own benefit, the things that you hope and desire for in the event that you have a healthy and safe labor/birth. This personal checklist will serve as a reminder to you of what you want to talk with your provider about - things that they might be accustomed to happening routinely but that you might not want/agree to routinely.

Now, with your birth preferences list in hand, how might a prenatal conversation with your provider sound? Let's take the example of Kirsten. Kirsten is planning on a hospital birth with a nurse midwife, Brenda.

Her words are in BOLD. The midwives are ITALICIZED. Positive communication is in PURPLE. Negative communication is in RED (with explanations as to why it is negative and does not facilitate informed choice/open communication).

Kirsten finishes peeing on a stick, being weighed, and having her blood pressure taken. She is now waiting in the exam room for her midwife, Brenda. Her midwife enters and pleasantries are exchanged.

Brenda, I wanted to ask you a few questions, since we are getting closer to the big event. Do you have a moment?

1. Reply 1 - I do, what can I do for you?
2. Reply 2 - I'm rather busy today, can we schedule for another time? 
1. Sure. This reply doesn't make it a sure thing that this conversation will ever occur. This leaves it open ended and gives no clarification as to how to make the conversation happen.
2. Sure, when I schedule this with the front desk, I will be sure to let them know to block out some extra time for this, sound good? This allows Kirsten to make sure it happens. It also puts the responsibility on her shoulders.

Now, they have established a time to talk, and they are discussing some points of her birth plan.

Brenda, I am hoping that, barring any emergencies or health issues for baby and I, that I can have a low-intervention, unmedicated birth. Knowing this, can you tell me your opinion of intermittent fetal monitoring, no IVs, vaginal exams, pushing in different positions, etc... (stipulating the above let's your care provider know that you are all on the same team about the health and well being of you and baby being first priority. Requesting their opinion reminds them that you are aware of different veins of thought regarding different practices).


I normally have the nurses check babies heart rate for 15 minutes every hour so that mom can stay out of bed as much as possible. I don't require an IV, if mom is hydrated and not having any pain medication or antibiotics, but I do prefer mom have a hep-lock in place 'just in case'. I normally do vaginal exams every 3 hours or so, just to see where we are at. I also like to see mom push in a variety of positions, although I might ask you to be in a different position if I think it might be more effective. (Brenda makes sure to tell mom they why for each reason... EXCEPT for the hep-lock. This didn't provider open communication or full-disclosure).

Thank you, I respect those answers. I don't feel comfortable, though, having a hep-lock 'just in case' because of the risk of infection/irritation at the sight for what possibly could be no reason. I would rather not have a hep-lock or IV. If it looks like I might have a medical need for one, though, then I will have no problems consenting to that. Do you have any qualms with this? (she keeps the lines of communication open by putting the ball back in her providers court. She also gives her reasons for not wanting one, along with a reminder that she is not unreasonable).

At this point, Brenda might make a few different comments/explanations:

1. I can see your point. Ok, I'll note that you are planning on not having an IV or hep-lock, but know that it might become necessary at sometime during labor and we will talk about that if the time comes.
2. I am still not comfortable with that. We have to have it there for emergency purposes, because, in an emergency, every moment counts. (Although this might be true, using terms like 'have to' place the role of power and choice in the hands of the provider, not the patient.)
3. I am still not comfortable with that. In the event that an emergency occurs, it will save us precious time to have access to the vein already in place. (Brenda does not give ultimatums for unknown possibilities. She gives reason without pressure). 

At this point, Kirsten might take one of three stances:

1. Ok, I can see the validity of this. Thank you for taking the time to explain to me your reasons. I don't mind having a hep-lock for those reasons. (giving consent, thanking her, and giving reason)
2. Ok (when, in fact, she is not ok with that reason or that intervention... all open communication and honesty has been shut down).
3. Thank you for taking the time to explain your reasons. It has given me a lot to consider. (this does not give consent or withdrawal from the conversation, it simply gives Kirsten time to evaluate her beliefs and comfort to come back to the conversation another time).

Let's do more prenatal role-playing. Kirsten is about 33 weeks and her midwife wants to do another ultrasound.

Well, I will schedule you for a follow-up ultrasound next week.

1. Ok (this does not promote open communication or informed consent)
   
2. I am curious, why do you want to schedule an ultrasound?

We normally do one around 33 weeks to check on babies growth and position.(she has not given enough information for informed consent and just disclosed this is a routine procedure).

1. I am familiar with the knowledge that late-term ultrasounds have a tendency to have a wider margin of error for babies size and due date. I really don't mind a second ultrasound as long as it will not influence your desire to induce or encourage labor sooner than is already noted as my estimated due date. (this provides a clearly defined parameter of your consent as well as shows your knowledge of the procedure, a valid choice to have the providers written or verbal agreement for condition of a specific intervention).
2. I have read recent reports that diagnostic u/s should be reserved for when it is necessary, since the risks of u/s have neither been proven or disproven. Would you consider this necessary or routine? If routine, I would prefer no ultrasound. (this requires your provider prove to you the necessity of the procedure, which continues open communication and gives the consumer information pertinent to making an informed decision)
3. Ok (this does not promote open communication or informed consent)
4. I really don't want one. No thank you. (this is a possible answer, but not a good one, because it doesn't allow your provider a chance to explain more fully, nor does it allow you to make an educated choice, you have not been given enough information. This answer could easily become a GOOD one after #1, #2, or #4 has been addressed, though).
5. What things would you be looking for, specifically, that cannot be ascertained through alternative means, such as external palpation, LMP, weight gain, and diet? (this gives your provider a chance to give you alternatives, support their reasoning, and/or otherwise keep you informed, exhausting all possibilities and reasonings)

I hope that these types of examples can help you to know how to have open and effective communication with your provider. To close, some thoughts to consider:

• Be polite - always thank them, use words like 'respect' and 'I understand what you are saying'.
• Be educated - you will hold more clout if you have valid reasons and education behind your reasoning. Uneducated choices are not choices, no matter how 'natural' those choices are.
• Be honest - if you don't understand something, ask for clarification, if you don't agree with their reasons or answers, don't be permissive and passive. 
• Be reasonable - if you need more time to consider their reasons, say so. If you may not like it, but see the validity of their reasons, say so. Remember, there are certain things in a hospital setting that will be expected to occur that wouldn't be expected to happen in a home birth or birth center setting because of legal necessity, not patient necessity.

Up next, open communication while in labor/birth/postpartum.