July 18, 2012 by Rebecca Dekker, PhD, RN, APRN
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Sarah's happy little baby boy

Sarah’s happy little baby boy

In my last post, I discussed the evidence for fetal monitoring. To sum up what I found, evidence clearly shows that intermittent auscultation (listening to the baby’s heart rate while feeling the mom’s contractions with your hand) is the best way to monitor baby during labor. However, only 3% of women in the U.S. receive this care. The other 91% receive electronic fetal monitoring, which increases the risk of Cesarean delivery. Many women are led to believe they have no options in regard to electronic fetal monitoring. However, this is one of the least helpful interventions for birthing that actually has proven risks. For women who birth at home, intermittent auscultation is the standard of care. On the other  hand, it can be extremely hard for women who give birth in hospitals to receive intermittent auscultation. But– it can be done.

I’d like to introduce Sarah, one of my readers, who recently succeeded in being the first woman (that she knows of) in a large teaching hospital in her town to receive intermittent auscultation. Her quest was not without struggle– when she went into labor, she ended up spending 2 hours in triage because of push-back from the on-call OB regarding 3 items on her birth plan: intermittent auscultation, no saline lock/IV, and letting the placenta deliver on its own. Here is my interview with Sarah. If you’re interested, you can read Sarah’s birth preferences (aka birth plan) here. It’s a great example of a low-intervention or “natural” birth plan.

Here is my interview with Sarah.

Tell us a little bit about yourself and your pregnancy.

As soon as I found out I was pregnant, way before you’re ‘supposed’ to be planning and celebrating, and way before I knew about possible birth preferences, I began putting together my birth team. The first person on my team was my birth partner—my extremely supportive husband.

We knew we wanted a doula because of the success many of our friends had with them and I quickly found a respected and experienced doula with availability around the time I had calculated would be full term.

Next, we chose a doctor based on a recommendation from a friend who had been given time to have her baby (she was 42 weeks) and had a low intervention birth. The doctor was in the OBGYN practice at the university hospital where I also teach. He was about our age and spent a lot of time with us at each visit. We thought he was great, though we knew that the possibility of actually having him on the date of delivery was slim.

Around 20 weeks into my pregnancy, I attended an open discussion group offered by a local maternity resource center. I had come to ask one question: “So, as long as I have my husband and my doula, it doesn’t matter who’s catching the baby, right?” The moderator offered a long and kind response outlining the reasons why this was not the case. At the end of the session, I was given the name of another care provider in Family Medicine at my university. My husband and I met with her briefly and immediately made her our care provider and switched practices altogether. As you’ll read below, this became an extremely impactful decision we made for having the type of birth we wanted, which was one with as few medical interventions as possible.

Tell us about your requests for intermittent auscultation, declining a saline lock, and allowing the placenta to be delivered without Pitocin. What made you interested in including those things on your birth plan? How did your chosen care provider respond?

I’ll start with declining the saline lock, since to me it felt like that decision was the cornerstone of our birth preferences. For me, the saline lock represented an anticipation of fluids and drips that I knew would not be part of our birth. And, it represented a hospital experience where I was a patient with a condition, rather than a healthy woman in an uncomplicated birth. Declining a saline lock guided the direction of our low-intervention birth.

As for intermittent auscultation, I was over 40 weeks into my pregnancy before I knew this was a possibility. Until this point, our birth preferences read: ‘We prefer intermittent monitoring.’ I learned about intermittent auscultation in passing from a friend. I looked into it using online resources and made the easy decision to change the birth preferences to read: ‘We prefer intermittent monitoring with a handheld doppler monitor’. I was very interested in this because of the mobility it offered. As opposed to electronic monitoring, where I would have been belted and attached to a machine, the handheld doppler didn’t disrupt me at all– I didn’t have the discomfort of something strapped around my belly, and I was allowed to change positions even during monitoring. The other research I found was alarming, particularly the rate of inaccuracy and false-positives (as in, a reading that indicates a problem when there is not one). Again, I wanted to eliminate hypothetical situations during the birth.

Finally, my opting for physiological third stage (natural delivery of the placenta) over active management (placenta delivery with Pitocin) was based on allowing my body the time it needed to complete the birth process. This decision didn’t go as smoothly as the other two. I was told in triage that third stage could not exceed 30 minutes (see below) and therefore I felt very anxious during this time, worried that I was on the clock. Additionally, in the 12 hours following the birth, I had more clotting than the hospital wanted me to have and I chose to have a shot of Pitocin at this time to reduce bleeding. Ultimately, even this was part of my birth plan since I wanted to avoid anticipated issues and only intervene when medically indicated, which in this case it was.

By the time we brought our birth plan to our Family Medicine health care provider, we had already completed our Hypnobabies birth education course and had done additional research using online resources. Our doctor still took the time to discuss risks and benefits of each of them, which we appreciated since we very much valued her perspective. She also let us know that there may be some issue with the hospital adhering with some of the points of our plan, particularly intermittent auscultation. She, my husband, and I determined that it was important to all of us to try to push through hospital policy, particularly if it meant that somewhere down the line it might pave an easier path for someone else requesting intermittent auscultation.

What was it like trying to get the hospital to follow through on these birth preferences?

This is where the importance of choosing a supportive care provider came to fruition. After arriving at the hospital with four copies of our birth preferences, we began getting push back from the OB on duty and she came into triage to discuss the risks of our birth preferences with us. According to the OB, the risk for intermittent auscultation was the fact that there was no paper trail of complications should there be an emergency where they may need the record for diagnosis. The risk of declining a saline lock was in case of emergency Cesarean. She was ‘fine’ with the placenta being delivered without Pitocin unless it took longer than 30 minutes to deliver due to the risk of postpartum hemorrhage. I was surprised by her repeated use of the term C-section and at one point in her explanation she mentioned NICU. In my deeply focused state (at the the I was somewhere between 5 cm and 6 cm dilated), I thought for a split second that the OB was jumping to the worst case scenario to frighten me out of our decisions. Then, I realized that thinking toward the operating room was just her training.

We told the OB that we appreciated the hospital’s position but that we were going to stay with our birth plan. In the end, it was our family medicine care provider, and my husband, who advocated on my behalf. At the end of the night, I realized that if I had stayed in the OBGYN practice, that this particular OB would have been caring for me that night. If that had been the case, my experience would have been dramatically different from the wonderful birth we had.

When you finally got past any barriers, how did using intermittent auscultation contribute to your overall birth experience?

I don’t have electronic monitoring as a comparison to my experience, but like I said, one of the decisions to use intermittent auscultation was based on having mobility, which I certainly got. I was allowed and encouraged to be in whatever position felt natural to me. I spent time on a birthing ball, in the bathroom, and on a bedside toilet with the bottom removed, and wasn’t near the bed until I was ready to push.

What I hadn’t anticipated was a sense of calm that came with intermittent auscultation. The monitoring felt very organic, different hospital staff held the Doppler at different times, and there was very little monitoring in the beginning, more near the end as my baby was moving through my pelvis. I was sometimes aware that my baby was being monitored and I’m sure sometimes not aware since the disruption was so minimal. Because I couldn’t hear the pulse constantly or see any flashing lines, I couldn’t jump to conclusions about how he was doing. What I could do was cue off of my care provider’s reaction, which was always very calm, so I never had even a moment of concern. I do distinctly remember feeling the monitor going on lower and lower at the end, which was very exciting.

Sarah, her husband, and her baby right after birth

Sarah, her husband, and her baby right after birth

What advice would you have for other moms who might want to request these things in a hospital birth setting?

Make sure your birth partner is on board and is as educated as you are about the risks and benefits of your birth preferences as you are, since you may not be able to be ‘present’ enough to deal with adversity. Choose your care provider based on their commitment to your plan. If they have a ‘we’ll see what we can do’ response to your birth preferences, consider changing care providers or even changing practices. It’s never too late to find someone with whom you share mutual respect, who makes you feel comfortable, and who wants to work with you. And yes, the right care provider for you is out there! If you make your decision early enough in your pregnancy and you know that there are parts of your birth plan that don’t follow standard protocol for your hospital, see if there are any hospital personnel with whom you could discuss your birth plan to avoid push back when you arrive in labor. Come to the conversation with them educated and with confidence.

(This is Rebecca again) I think Sarah described her experience– and her insights– beautifully. I think we can learn a lot from her story about how to request evidence-based monitoring at birth.  And I am so thankful to her for paving the way for women in her community to receive evidence-based monitoring at that particular hospital. For women who are birthing at home or in birthing centers, you probably don’t need to worry about monitoring since intermittent auscultation is already standard in those settings. But for women who are giving birth in hospitals and want to receive intermittent auscultation, I’d like to suggest a potential plan of action. (But FIRST, read my Disclaimer). Of course, as Sarah pointed out, some of these action points may or may not be feasible, depending on how close you are to your due date.

  1. Have a pleasant discussion about intermittent auscultation with your care provider. State that you are really interested in intermittent auscultation. Emphasize that you want intermittent auscultation with a handheld Doppler—not an intermittent electronic fetal monitor. Find out from them if intermittent auscultation is used at your chosen place of birth.
  2. If your midwife or doctor is interested in helping you out with this, but they are not familiar with the method, give them the intermittent auscultation guidelines from the American Congress of Obstetricians and Gynecologists , the American Academy of Family Physicians, the American College of Nurse Midwives, and the Association of Women’s Health, Obstetric, and Neonatal Nurses (all freely available onlnie). Likewise, if your care provider is NOT interested, you can also hand them these same guidelines.
  3. If you meet with extreme resistance from your care provider, and if this is really important to you, then you might either A) consider choosing another care provider or B) let them know that you are thinking about refusing consent for the EFM and that you would like to choose intermittent auscultation instead. They may not “let” you do this or state that this is not “allowed,” and threaten to fire you from their practice. I would hand them the ACOG guidelines. And reconsider again whether you want this care provider at your birth. If you have no other option and “have” to stay with this care provider, weigh the benefits and risks of creating adversity with your care provider versus your desires for intermittent auscultation. Is it worth it to create adversity for this particular cause, or not? Adversity can be a bad thing in a birth setting. Also, you need to ask yourself, is this a warning sign that this particular care provider might not honor any of your other requests related to birth preferences?
  4. If you are going to be a trend-setter, or one of the first people at your hospital to receive intermittent auscultation, I would contact the nurse manager of the labor and delivery unit where you will be birthing, and set up a meeting or phone conversation with them to discuss your care. To set up this meeting, you can call the labor and delivery unit and ask to speak with the manager. At your meeting, make sure you bring the guidelines listed above. In particular, the American Academy of Family Physicians guideline has a helpful segment on how to implement intermittent auscultation in a hospital that is not used to using it.
  5. In the month before your birth, confirm that someone who will be at your birth (your doctor, midwife, nurse manager, or nurse) is comfortable, trained, and experienced at intermittent auscultation with the handheld Doppler or fetoscope, and willing to provide this care. You do not want to get there and have nobody that knows how to do this.
  6. Ask your care provider to write “intermittent auscultation” in your orders and notify the hospital so that when you arrive this wish is honored. Have your birth plan signed by your doctor and already placed in your chart. The hospital staff might think you are weird or crunchy or a crazy natural birthing mama. But you know what? This isn’t weird or crunchy stuff. It’s evidence-based stuff.
  7. If you meet with EXTREME resistance from your hospital about intermittent auscultation with the handheld doppler, you could request that they hold the electronic monitor to your abdomen for intermittent auscultation—instead of having it belted around your waist. Auscultation is an option the staff can select with most electronic fetal monitors. That way you can be in whatever position you want to be in, and they bring the monitor to you, and hold the sensor up to your abdomen, listen to the baby’s heart rate, ande palpate your contraction. This will also allow them to “capture” the brief reading on their computer in case of a lawsuit (which is mostly what they are worried about).
  8. If you meet with extreme roadblocks along the way, I would write a letter to hospital administrators. You can usually find out their names and sometimes their emails on the hospital’s website… if not, call “Information” at the hospital main number and ask for “patient relations.” Once you get someone on the phone from patient relations, ask them to pass along your letters to these people. You could include copies of the ACOG, AWHONN, ACNM, and AAFP guidelines (links above) with your letters. Send them to:
  • Chairperson of OB/GYN
  • Nursing Manager of Labor & Delivery
  • Chief Nursing Officer
  • Chief Medical Officer

In the end, there are several ways to obtain evidence-based maternity care when it is not routinely offered. You can be strong, determined, and resourceful– like Sarah– and fight for it on your own (with help from your birth partner and your care provider). Women like Sarah are birth “pioneers” and we need more women like her! However, I would also like to suggest an additional way that we, as women, could get this evidence-based care. We can fight for it together. We can join together with Improving Birth to rally on Labor Day for evidence-based care for women. Look for an article about Improving Birth’s mission, coming soon!

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