Talk It Out - Part 4

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. This is the final installment from the Talk It Out series. Parts 2 and 3 can be read prior to this.

Hopefully, by the time you are in labor, you will know how supportive your provider is. Your responsibility to ensure full and informed choice, though, doesn't end prenatally.

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, we have reviewed some examples of positive communication, and we know what our goals of positive communication are, let's talk about how to maintain that communication during labor and birth.

When you are in labor, anticipate that you will be your most vulnerable and easily influenced. For this reason, it is VITALLY important to have the previous conversations beforehand; this sets the stage, allowing you to, prenatally, assert your autonomy, as well as your patient's rights - which are both inherently connected to one another.

The Educating Acronym
While in labor, I am sure that you have heard of the BRAIN or BRAND acronym. If not, let me explain them both herein:

Benefits - "what are the benefits of the procedure or intervention being suggested?"
Risks - "what are the risks of the procedure or intervention being suggested?"
Alternatives - "what other alternatives can be considered?"
Interventions - "what other interventions accompany this procedure or intervention?"
Nothing - either "what could vs what will happen if we choose to do nothing at this time?"

Benefits - "what are the benefits of the procedure or intervention being suggested?"
Risks - "what are the risks of the procedure or intervention being suggested?"

Alternatives - "what other alternatives can be considered?"Nothing - "what could vs what will happen if we choose to do nothing at this time?"
Decision - either "how much time do we safely have to make a decision?" or "We have decided to _____."

My preference? BRAIND.

Benefits - "what are the benefits of the procedure or intervention being suggested?"
Risks - "what are the risks of the procedure or intervention being suggested?"

Alternatives - "what other alternatives can be considered?"

Interventions - "what other interventions accompany this procedure or intervention?"

Nothing - either "what could vs what will happen if we choose to do nothing at this time?"
Decision - either "how much time do we safely have to make a decision?" or "We have decided to _____."

We can write the best birth plans possible, but, in the end, labor is organic and cannot be scripted. Thus, making sure you have BRAIND each possibility before making a decision will ensure that you are making careful, competent, and fully informed decisions.

An example of this can be found with the commonplace conversation of pain medication for labor and birth. We will use our fictitious mom, Kirsten, and her nurse midwife, Brenda, once again, for example.

Kirsten: "I want an epidural"
Brenda: "ok, I will tell the anesthesiologist, he will come in to talk about benefits and risks, and then you can have the epidural".

This is usually the end of the conversation for most care providers and their clients. A fully informed patient would continue:

Kirsten: "what are the benefits of an epidural at this point in MY labor?"

Brenda would then have an opportunity to share Kirsten's specific labor and the benefits she might gain from it (i.e. long labor might mean she could get some rest, a tense laborer might be able to finally release her pelvic floor allowing dilation to complete, creeping blood pressure can sometimes be brought down by an epidural, etc..).

Kirsten: "what are the risks of an epidural for MY labor?"

Brenda would then have a chance to discuss implications such as babies position and how an epidural might influence babies chances of moving into OFP, her lack of dilation or near complete dilation (not much dilation might mean labor might slow or become ineffective, necessitating pitocin whereas nearly complete dilation might mean she might not choose to have an epidural), her medical history (i.e. if she has a history of low blood pressure).

Kirsten: "What things could I try other than an epidural?"

Her care provider may have some great suggestions like walking, the tub, the birthing ball, and others. Her nurse might also. It would also give her doula, if she chose to have one at her labor, a chance to give more suggestions... the more minds working for you and your birth, the better.

Kirsten: "What other interventions will be or might become necessary?"

Brenda would have a chance to tell her that an IV will have to be ran, a catheter will most likely be used to urinate, she will most likely not be able to get up from the bed from that point on, and continuous fetal monitoring will be used.

Kirsten: "What could vs what will happen if I decide not to get the epidural?"

Brenda would have a chance to point out that many women ask for epidurals during transition, the time between 6-9cm, that usually culminates with the urge to push within an hour or two. She would also have a chance to talk about the fact that most anesthesiologists need around 45 minutes to get there and get the epidural placed and that Kirsten can take that time to decide if she really wants it, which leads right into the D of BRAIND - making a decision or taking time to make the decision.

Putting The Proverbial Foot Down
Now, unlike before labor and birth, your birthing time necessitates quick thinking and leaves little room for 'conversation'. In truly emergent (not necessarily emergency) situations, where your care provider may be requesting you to make a split second decision (i.e., about to cut an episiotomy, about to deep suction baby, about to break your water, etc..) politeness will come second to refusing or accepting an intervention or procedure.

For this reason, I am going to give you different scenarios and how one might work within them. I like to call this the Stop, Look, and Listen approach

Your care provider is doing a vaginal exam and wants to break your water. Without asking consent, (s)he picks up an amni-hook:

STOP: Get your providers attention... in whatever way time permits. This is usually a hasty and/or direct order, so as to stall their hand/the procedure. Sometimes, it warrants raising your voice.

• "Wait!" Alternatives of this can be "No!", "Stop!", or "Dr. ____" .

LOOK: Note what is happening, what you are worried about, what you are witnessing, or what you want clarification on.

• "I see that you are trying to break my water." Alternatives might include "I see something in your hand", "what are you doing?", or "what do I see in your hand?"

LISTEN: This is two-fold, first, to get your provider to listen to your wishes and second, to listen to theirs.

• "I don't want my water broken." Alternatives to this might include "I expect/hope you will discuss any intervention with me before applying it to my health care." This will allow them to express their reasoning, hopes, and expectations of the procedure they want to complete.

Again, Stop, Look, and Listen are best used when you have to make something happen right then and have to, for the most part, do away with the pleasantries, but still allows for open communication. If your provider does not respond to the first Stop, Look, and Listen, you may have to repeat the Stop part until they do.

In truly emergent situations, "Look" can be omitted:

• an example would be episiotomy - STOP: "Don't cut me(her)!", LISTEN: "I/she would rather tear."
• another example would be deep suctioning at the perineum - STOP: "Wait!", LISTEN: "use the bulb syringe."

If you are not in the place to use Stop, Look, and Listen, your advocate (partner, husband, or other family member) should do this for you. Your doula can remind you or make you aware of something that might be about to happen, but they cannot make these choices for you.

In Closing
Remember, at all times, you have the right to refuse or request any procedure or intervention. This includes IVs, monitoring, discharge from the hospital, pain medications, surgery, and any and all touch, including vaginal/cervical exams, blood pressure readings, AROM, and the like.

Your goal should be to make your wishes be known and to have them be followed throughout your prenatal and labor/birth/postpartum care with the best, most open communication possible with your care provider. Open, honest, and unhostile communication will ensure the most pleasant care and empowering experience, which is why we have discussed all scenarios, those which we can be thoughtful of our words, and those when pleasantries may take a back seat.

Here is to hoping for open communication and honesty between providers and the women they serve!