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. 



Mar 04, 2009 09:16 PM

An OB's Birth Plan

by Poppy_Petal


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......


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.