Wednesday, October 8, 2008

Next Question for Everyone...

Thank you for all the feedback on the natural labor posts. As a new nurse, these are the things that I'm still trying to learn, so all the feedback, ideas, thoughts are great and very, very informative.

So my next question is: What are the things that help the most if you're trying to go natural, or even if you have pain meds? What are the things that you as a laboring mom want to hear, what can I as a nurse tell you that is going to make this process what you want it to be? What things can I do to let you know that you're supported? I know labor is different for everyone, but as a general rule, what works? I told a couple of the nurses the other day when I had someone "unblocked" I feel so dumb standing by her bed saying "in through your nose, out through your mouth" "keep breathing" "good job" "you're doing great" I would think that would get old after about the 2nd contraction, and if that's all my nurse kept telling me, I think I'd rather her leave! I feel funny just standing and hovering at the bedside too, but I feel like a horrible nurse if I leave and let her lay in the bed crying on her own.

So what works, what do you want to hear, do you want me to stand beside you, do you want me to go away and come back every 15 minutes to see how you're doing? What DON'T you want me to say? Do you want me to keep offering pain meds or anything after I've offered them once or twice and you refuse them? Obviously there are things that I can't do (especially with inductions, but that's just my hospital rules, not mine), but really, what things can I offer that really help?!

11 comments:

  1. I love your questions and that you care so much. I have had 6 babies with 4 different OB's in 5 different hospitals. Of all the nurses I've had only 3 were really good. I've had all vaginal deliveries(yeah!) and births with no pain meds at all (my preferred mode of laboring) and births with all sorts of epidurals - good and bad. I'm the weird kind of patient that fooled many of my nurses because I labor "comfortably." I found that being left alone with maybe only my husband so that I could get into that labor "zone" was very helpful. Breathing exercises hurt, but low groaning sounds really helped me get through the contractions. Ideally, I would've loved a caring nurse who checked on me every 20 minutes to see how I was doing and if I refused pain meds once, don't ask me again. You can say "Let me know if you want any pain relief, otherwise I won't offer it again." Also, reminding me that any rectal pressure or that "I have to poop" feeling should definitely be reported right away to the nurse. (I had nurses deliver two of my babies because I tended to deliver precipitously.) Big help: keep distracting people away from the laboring mom, even if she wants them around. If you can see they are too distracting to her, ask her if they can be asked to leave for just an hour so that she can rest. She might not know she needs this, but any perceptive nurse will know who is really supporting her and who is not. Encouragement and care is so crucial to any laboring mom. They are so vulnerable and at the mercy of their caregivers - you!I'm sure you're a great nurse and I so wished I could've had you for even one of my babies' deliveries. God bless you!

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  2. As a nurse, be real. Encourage the mom when she's doing great. If you see her panic in transition, let her know she's in transition...or at least how to calm down. I recall a nurse in my first birth said to relax my chin and shoulders as tensing makes it worse. She said to pant in a he he he hoooooo....so that I wouldn't hyperventilate. It somehow helped. "If you want to, try this..." is good. I also think it's been good for my nurses to make eye contact, and not sound panicky even if they should panic. Chatting with me has been nice, not being a "know it all" but offering what "might work." Offer showers and water when you can. Listen to mom, sometimes we give clues without saying things directly because we don't have the energy. As an experienced birther, my signal is telling the nurses I have pressure or have to poop. I know they hear this, I have told nurses about the ring of fire (and ended up with baby on the bed and no one catching). I want to be treated like I am in the room, even when I'm in pain. Talking like I'm not there is hard on me, and makes me feel like a freak, frankly. Nurses who try to get baby to me faster after birth (we have meconium, so that prompts baby to be taken) give me confidence too.

    If you have to monitor, offer options if mom is not comfortable with it. Let her go to the bathroom, or give her a bedpan if she cannot go across the room. Dignity! I had a nurse actually tell an OB who was willing to let me move around that I had to stay in the bed with the O2 on one side and monitor/iv on the other. My mom (a nurse) said she could have offered longer tubing for the O2. The OB actually let me off the O2 and let me out of the bed.

    Don't do cervical checks and stretch the vaginal opening unless the woman wants this. Ouch. If you find yourself doing an internal check every 10-20 minutes, that's too many unless ordered. Don't keep fingers in between contractions for no good reason. Don't stretch the cervical lip out of the way!!!Ouch. Offer mom a wedge for her back if her baby had a decel earlier when she was having a cervical exam, or another position (my nurse put me flat on my back and baby had a sudden decel...then kept checking me often and it scared me that my baby was going to have more decels...and she had me pushing on my back, flat).

    If mom asks for a drink and you say "no" you have to offer something...popsicle...or allow ice chips or a sip. I was so parched with all the pushing (starting at 9cm and OB said labor down, nurse started all this again).

    Nurses I enjoyed knew I was "close" by my behavior, knew to stick with me when I was closer to delivery, but leave me alone earlier in the process. They knew to listen and watch my cues...and that made all the difference. Good nurses never made fun of me, not even to my husband. They did laugh with him when my eyes were closed (because I apologize for moaning when I'm not on pain meds...profuse apology and it's ridiculously funny). Good nurses respected my husband. They talked with him like he was a friend, and talked with me like they were my aunt or sister. They treated me like I knew my body, but if they had information I was unaware of that could help me, they gave it. If they saw something wasn't working, they offered to help.

    By the way, if I don't have an IV I drink. I do better if I'm not parched. I have had more trouble with the IV in that I swell like a stuck pig (this last time the arm bands were so tight the next day I was sweating under them and they hurt). I prefer to hydrate by mouth if possible.

    Okay, I don't know if that helps as I rambled. But, I will say your attitude does a lot for us apologizing, moaning, growling, scared of intervention mommies out here. Don't like internal checks. If you get a mom of five or so, know the baby can be high for a while. Then suddenly, at 4cm, baby is crowning because mom went to 10cm with no one aware. The floating baby with intact water has been good for my babies and for me.

    Oh, offer pain meds and if mom says no, then you don't need to ask again. She'll let you know.

    I wonder how often you've seen a decel when mom is checked on flat back? Flat back pushing after such a decel is very scary to a mom...

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  3. I've had two home births, the first I had my CNM and her assistant/doula with me practically the whole time (9 hours start to finish, not bad for a primip, eh? Obviously, they had some "getting ready" and "travel time" so they missed probably the first couple of hours), and I think part of what you need to know is simply going to have to be learned by trial and error -- although becoming DONA certified wouldn't hurt! :-)

    My mw & doula *just knew* the right spot to press on my back, when I had back labor. For me, just them being there was helpful. When they said encouraging things, I swear I was schizophrenic, because at the same time, half of my brain was totally believing it, and the other half thought it was a load of bull. :-) But I believed them more than I believed my husband -- he sounded like he was rehearsing a script. He tried, bless his heart, but he just didn't "have it."

    You can read my second birth story here, but the short version is (different state, different midwife), I didn't call my midwife in time and had a completely unattended labor (let hubby sleep because he had to work), and my sister caught the baby. Some people think that laboring completely alone is the ideal, but 24 hours of painful but widely spaced contractions, and feeling not just alone but abandoned is not ideal. It more firmly grounded in me than ever why women have historically had other women tend them in birth. I'm an ardent natural-birther, but with every contraction for several hours from like 12-3 p.m., I thought "epidural!!!" and would have gotten one, except I didn't have anyone to drive me to the hospital at the time, I hadn't even called the midwife, and I didn't want a hospital birth with all the intervention. The blasted ctx never did get any closer than 7 minutes apart, and they were never regular.

    One problem I see with so many hospital-birth stories is that there is a "one size fits all" mentality: doctors like things their way; nurses are used to doing things a certain way; hospitals have protocols they like to have followed. Birth is not like that. What may work in one birth may not work in another -- even in the same woman. Some women will want to be alone; others will want you to sit right beside them. Even within the same labor, some women may be stand-offish at first, and then cling to you by the end.

    The best thing you can do is to *care* about the women. Listen to them, learn from them, follow their lead. Don't look worried -- they will think that something is the matter with them or their babies. Tell them that you would like to let them off the monitors, but hospital policy won't allow it (also explain to them that it's for the safety of the babies, when they've had Pit, because some babies crash or go into fetal distress, so they need to have continuous EFM to make sure that doesn't happen). And if they aren't allowed to get up at all, get 'em a bedpan! My sister had the full standardized medical experience for her first labor (planned a natural birth, but had no tools or knowledge to make it happen), and the nurses told her she had to have continuous monitoring (I don't think she'd gotten on Pit yet, even), and wouldn't even let her out of the bed to go to the bathroom, but wouldn't bring her a bedpan either. Eventually, she got up and went to the bathroom, and the nurse chided her for taking off the belts!

    Anyway, there are lots of tricks that doulas and home-birth midwives have to make labor easier, including position changes, applying hot or cold compresses, hip squeezes, counterpressure, and sometimes just a loving touch and a kind word.

    -Kathy

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  4. So, I've never had a baby in a hospital, but my husband could say, "You're doing a fantastic job," about 3 million times and it NEVER got old. Reminding them to breathe is important, if they are not doing it. Encouraging them to find positions they are comfortable in is HUGE. I changed positions every 2-3 contractions, as my body dictated. Without drugs, you can actually hear your body tell you where it needs to be. I've had 3 of 3 unassisted home waterbirths - the smallest one was 8# 6oz and the largest was 10# 4oz - no tearing, plenty of small complications, but I trusted my babies, so I listed to my body. Listen to the mom, they know their body. And when transition occurs, tell them, "You just have to get through this one contraction." Once they do, give them kudos and tell them that they just need to take once contraction at a time. Transition is the shortest and hardest part of labor, so it's almost over. This will help them stay away from the drugs, since many moms get the epidural, when the self doubt comes in and the baby is out before the epidural takes effect. After 27 hours in labor, I heard myself cry and say, "I just can't do this anymore." When I heard that, I KNEW I was in transition, got a 2nd wind and my first son was born 2 hours later, but it felt like 10 minutes. One contraction at a time. Good nurses make more of a difference than the OBs when mom is in labor. We all know they are the ones who make or break a birth plan. Thank you for listening.

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  5. I think in some ways this is where a birth plan is helpful. You have an idea of what mom wants in her birth. In Hypnobabies we call them Birth Preferences, because you can't plan a birth, but you can have preferences of ideally what you would like.

    I used Hypnobabies (hypnosis for childbirth) with my last birth and was completely comfortable without any pain meds for my whole birth. But this requires practice and preparation before hand, so not helpful for a nurse with a patient who hasn't practiced.

    BUT, be aware that all moms are very suggestible during their birthing time. So if you say to a mom who is laboring beautifully, "You are doing well, but when your water breaks it will start to hurt." (I had nurses say this to me 3 times with my 2nd birth and not surprising it started to hurt when my water broke! With my next birth I was actually MORE comfortable after my water broke.)

    So instead of assuming what WILL happen (even if it happens to many of your patients) just remain positive and encouraging.

    Really I think this is so important and nurses and care providers don't realize the impact of their words on patients.

    If a mom says (in her birth preferences or verbally) I don't want pain meds. Let her know that is fine and you are happy to get some if she asks, but you won't ask. (unless you have to, I know some hospitals have that rule!)

    I have seen a mom doing great unmedicated and then a nurse comes in and says, "If you want an epidural now is your chance, the anesthesiologist is heading home. You are doing fine now, but maybe not in an hour." This mom then started to second guess herself and worry, was she going to be struggling in an hour. The nurse didn't mean to, but it undermined the moms confidence.

    So stay positive and encouraging to NCB moms. Some moms do want to hear the encouraging words and want you to stay there by their sides. Some just want to be alone. I think it is fine to ask. Would you like me to stay or would you like some privacy? They'll let you know!

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  6. I also think it's wonderful that you want to keep learning and exploring.

    There are so many great ideas in the comments already - I second Penny Simkins' The Birth Partner for concrete ideas on how to support women during birth, and I love her video 3R's: Relaxation, Rhythm, Ritual, - it shows lots of unmedicated births and how moms get thru each contraction (it follows several moms, showing a contraction from early labor, active labor, transition, and 2nd stage labor).

    I think one of the biggest things is listening to women and doing as much as possible to work with them as an individuals. A lot of the questions you ask in the post would be (I think), completely appropriate to ask the laboring woman and get *her* answer - "Do you want me to stay and breathe with you, or do you want me to check back with you in fifteen minutes?" for example, or the pain med question you ask in the post. The answer to some of these questions might be in a birth plan!

    For me, what really helped was: changing position (offer physiologically-helpful positions that involve movement - birth ball, swaying, walking, slow dancing and/or to help a specific situation - knees/chest or hands/knees in back labor/precip labor comes to my mind); water (offer to fill the tub if you have one, start the shower etc. - that helps lots of women sooooo! much); fluid (juice, water, ice chips, popsicle whatever); staying out of the way when that seems to be what the family wants (like me) or being a more active presence for someone who might need more support/distraction.

    Oh - and realizing that just because a woman acts like she's in agony - thrashing, moaning etc. - that might be exactly what's helping her cope. It's her experience, and if that's what she would prefer, and it's not hurting her/the baby any, then ideally she would be supported in that choice. It might truly be her preference to thrash/moan than to have a medicated birth. I understand that might not be some nurses' preference, but that's when it comes back to the fact that
    this is the laboring woman's experience, something she may only do once/twice/three times in her life.

    Of course the hospital/drs have specific policies - but just staying open to working with women as individuals within those limits as much as possible would be huge, I think.

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  7. Oh, yes, I forgot, and Christina's comment reminded me -- just because a woman is vocalizing doesn't mean you are abandoning her if you don't offer pain meds. Vocalizing is the only way to get through some contractions without pain meds, but it doesn't mean we're in horrible pain and/or that we want drugs. You could be discouraging ("Would you please be quiet? you're disturbing the other women") or you can be *encouraging* ("Oh, those labor noises are great -- you're really handling those contractions well!")

    Little things mean a lot -- I was extremely suggestible during labor! Don't underestimate how much the way you look, or the tone of your voice, or the words you choose may influence someone. If someone had asked me, "Do you want your epidural now?" when I was in labor, I would have said "yes" even if I was handling labor fine before, because I would have taken her question as a comment -- that I must not be handling labor well, and I needed an epidural because I obviously was horrible at this whole birthing thing. She wouldn't have meant it that way, but that's the way I would have heard it.

    -Kathy

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  8. Oh, in labor I like to be told the truth, and listened to. My last nurse told me that pushing baby out on my back would get the baby out over my backbone. I had birthed five babies before, mostly sitting up or in only a slightly reclined position. I am the one who has always put my bed up, the nurses recline it too far. When this last nurse had me flat back (I already mentioned the decel after a flat back cervical check) I became scared and didn't trust her. I would say, "but I've always pushed in an upright position" and she'd explain it away. She told me "you'll love using the stirrups while pushing." I'd had five babies before, but she spoke to me as if it was my first time. She also bribed me a lot. "I'll let you in the shower after one cervical check." Didn't happen. She promised, and then probably because I was flat back baby had a decel. She was freaking out after she had me on my left side with fluids...baby's heart was in the 80's on the monitor. I asked to sit up, she said "no" and then I went ahead to sit up and she told me not to, said she wasn't comfortable with that. However, when I sat up the baby's heart rate immediately went to 124.

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  9. Believe me - anything you say that is encouraging, will help mom get through her contractions. I remember listening to my nurse tell me, over and over again, about how good of a job I was doing, beautiful work, keep it up, etc. This was at my 3rd birth. Totally unmedicated, and went pretty quickly too. My eyes were closed, but hearing her voice say those encouraging words was....like my own personal port in a storm. She probably had no idea of how much it helped me get through each contraction.

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  10. Alright! I haven't had a chance to read all of the comments that were given, but here's the things that come to my mind:

    - Sometimes I talk women through contractions, and sometimes I'm just silently supporting them with a calm exterior. It depends on the body language of when I talk - the woman gives me the clues I need. Often I talk after the contraction and not during. And I try not to talk to others in the room while the woman is contracting - it is often very distracting.

    - If I am talking a woman through contractions, I'm usually saying the same 3 or 4 things over and over, just like you said. And a woman in labor usually doesn't care. She's in Laborland...it's a completely different place. I talk slowly, quietly, with few words. Sounds like you are doing great.

    - I try to match my words to the personality of my client. Some of the crunchier moms want to hear about how they are working with all the 300,000 other women who are giving birth today, or feeling their contractions as their inner power, etc. Totally not necessary and has to be both your and her style.

    - I'd ask near the beginning of labor what her preferences for pain meds are. Look up the "Pain Medications Preference Scale" and that should give you a bunch of clues about how to talk to a woman before strong labor hits about how much and how to offer pain meds depending on the situation. Most moms who strongly want to go natural don't want anyone to offer pain meds - unless it's a last ditch attempt to avoid a cesarean (anterior lip that just won't go away; early urge to push and a cervix stuck at 9cm no matter what positions are tried; a gal at 3cm for 6 hours or something).

    - Often if a woman starts making a little noise, I'll say gently, "What was that sound you just made? Would it feel good to make it a little louder next time?" Encouraging noise can really help a woman cope on her own terms, and let her know you're supportive.

    - As for a mom crying, sometimes I ask gently, "tell me...what is going through your head right now?" And sometimes this gives me some clues and I can alleviate fears for her that are holding her back (I'm afraid I'll tear; I'm afraid that X will happen that happened during my last birth etc.) and I can clear up something for her or offer her emotional support.

    Hope these ideas help! Really enjoying your blog!

    Kristina :)

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  11. Getting certified as a doula is a great idea! It will really clue you into how to read your patients and help them.

    CAPPA has a home study course so you could do it in your spare time without attending a workshop.

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