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Thursday
Jul212011

Sacred Trust

Science & Sensibility’s post today, Sacred Trust of 24/7, speaks, almost gingerly, of the Sacred Trust between a physician and a patient. Dr. Michael Lu says:

“I know I could talk my patient into anything, and most OBs know that.  But that’s a misuse of that trust.  Yet there is that sacred trust.  I don’t know how to change that culture.  Maybe the trust is misplaced.  And this is what I haven’t figured out, if we replace the OB with a team, can you have trust in a team the same way you have a trust in your OB?”

But, it isn’t just with OBs that this trust occurs… and is exploited, but also with midwives. One needn’t look far to see this in motion every single moment of the day.

-         No, you don’t need IV antibiotics; Hibiclens does the same thing.

-         No, you don’t need Vitamin K; it causes leukemia anyway.

-         No, you won’t need Pitocin; we have herbs for hemorrhage instead.

-         No, you don’t need to go to the hospital; you’re just taking longer than normal, but it’s okay.

-         No, you aren’t taking longer than normal; it’s just a variation of the norm.

-         No, you don’t need antibiotics; just take cranberry capsules and drink lots of water.

-         No, you don’t need to be induced; some pregnancies just go over 42 (43, 44) weeks.

-         No, you don’t need to take the GTT; Gestational Diabetes doesn’t really exist.

I could go on and on, but you get the gist.

We in the Natural Birth World are even taught to distrust everything an OB says, but who teaches how to decipher who is telling the truth or not? Why are the very few of us who suggest there be some discretion with what midwives say vilified? I don’t understand how a woman can put her all her trust in one set of letters after a name and not any in another set of letters (or lack of letters!).

Perhaps the UCers are nodding and saying, “See! This is why we only trust ourselves!” But, even that isn’t true because they’ve been sold a bill of goods as well, that birth is always normal and good with a great attitude and no fear.

Who really speaks for the woman? Who are the providers (or doulas) who tell the truth? How can a woman find a Truth-Teller? I don’t know if there is any specific way for a woman to know if her provider is completely on her side except through referrals and her own examined experience.

I really, really love the idea of a group discussion, not just a second opinion, but a nurse, doctor, midwife and maybe another doctor, who decide if a woman gets cut or not. My own preference, of course, would be an experienced doula in the mix, but that would be a fantasy stretch for providers to consider. And I know in the case of emergency, there’s no time to create a quorum, but the great majority of cesareans are not that type of emergency.

Do others have ideas on how to know if a provider really is giving complete Informed Consent or just offering what s/he is capable of doing? This is a really important question and one I hope will be asked amongst the different factions of the Natural Birth Community.

Reader Comments (12)

This is why, I think, I have consistently come to this particular blog for information on birth practices. I value your opinions because they are consistently backed up with solid, evidenced-based rationales. Whether obstetrical methods are founded under assumptions of birth being "inherently pathological" or "inherently perfect, unless traditional medicine mucks things up", they are both assumptions not in keeping with evidence. I am in the medical field, and I often feel internally at odds with these diverging schools of thought. It is refreshing to hear the voice of someone who calls for trust in BOTH sides, who can separate facts from assumptions, and who understands that necessary interventions do not preclude from us the power and beauty of birth. Thanks for a great post!

July 21, 2011 | Unregistered CommenterKatie

I want, very much, to be one of the truth tellers.

I get so frustrated when the "natural birth" types I know preach "evidence based" when the evidence is in their favor and then dismiss or ignore the evidence when it goes against them. Not every OB thinks only of his golf game. Not every hospital nurse wants you to get your epidural and shut up. Not every drug can be replaced by an herb. Sometimes birth betrays our trust.

With a great attitude like that, you are well on your way to being a Truth Teller. *giant hugs*

July 21, 2011 | Registered CommenterNavelgazing Midwife

This was the one thing I really liked about the hospital where I had my caesarean (for footling breech); after that first shocking scan to confirm a suspected breech, they first sent in a consultant to explain why, in a hospital where breech birth was supported, the footling position was considered too risky. He talked right over my head to my husband and said 'If she were my wife... I would tell her, these little babies are too precious to risk.'

The nurse midwife came back in, found me boiling with fury, and I said 'He played the dead baby card. I want a second opinion. In fact, I want a third opinion.' And this was what I liked; they listened to me, and they brought in a senior consultant, who talked to me as if I were a sensible, intelligent human being; he discussed the flaws of the Hannah breech trial, he talked about the mechanics of breech birth, and then he broke down the statistics of footling breech outcomes in a calm and reasoned way. Then they brought in the Head of Midwives (who deals with non-complicated births, and was very pro homebirth) and she talked to me about the two footling births she'd witnessed, again in a non-fearmongering way. And after that my doula arrived, as she had a relationship with the hospital staff, for an informal chat about what I wanted to do. I never felt as if I was being bullied into the caesarean; rather, they took all afternoon with a stunned and then rather weepy patient so I could reason my way through to a decision.

I suppose that this is how I imagine a team situation would ideally work; you'd have the surgeon, the experienced midwife and the doula all working together to inform the patient. (And if the first surgeon is an ass, you get a replacement.)

(Consultant #2 apologised for Consultant #1; he said that the first man had spent most of his obstetric career practising medicine in a developing country where he'd seen a lot of bad outcomes. I still don't think that excuses the misogyny of talking to my husband rather than to me.)

July 21, 2011 | Unregistered CommenterT

Amen, Barb! I get a little freaked out when I read posts from natural birth advocates that smack of just a little too much "woo" and not enough science. I love your writing! Keep it coming!

July 21, 2011 | Unregistered CommenterJen B

My midwife provides me with the research for me to go through and allows me to make up my own mind. I think that is the best a care provider can do.

July 22, 2011 | Unregistered CommenterJenna

But, what if the research she's showing you is what she wants you to see? In my Informed Consent, I list a variety of places to find information. From doctors, nurses and other midwives to medical texts, medical websites and even friends and family members. A woman *must* share in her own education, not relying on only one avenue of information. If she does that, it can be a set-up for manipulation. It might be *the* perfect solution and the provider might certainly be offering balanced information, but, in this instance, I believe variety is the key to figuring out what the woman wants... and *needs*... to do for herself and her baby.

July 22, 2011 | Registered CommenterNavelgazing Midwife

I think having a quorum to decide on a c/s is a great idea...however, why would a doula, who is specifically defined as a non-medical provider and whose sole role is to support and educate mom, be involved in making a medical decision for the mom?

July 23, 2011 | Unregistered CommenterEmily

HAHAHAHAHA! You're right! Isn't that a hoot that I was thinking of my SELF?! Sheesh. You're right, Emily; nix the doula.

July 23, 2011 | Registered CommenterNavelgazing Midwife

I share a lot of your frustrations with other midwives AND physicians. I am becoming increasingly aware as I finish my first year at Nizhoni that my place in the world of midwifery will probably be serving those who trust and believe in science and medicine, as I do. I am enthusiastic about homeopathy and herbal remedies, but I'm always the one in the class asking, "But don't antibiotics work really reliably for thus-and-such condition?"

I see in your life and past practice a lot of where I hope my future will be. I want to be a bridge of reasonable practice, someone who is comfortable talking to and about physicians without (unduly) bashing them, and someone who can hold my head up and talk about birth as a natural, non-medical process. My teacher always says that the best advice she ever received as a young midwife was to transfer when necessary. I believe in medicine! I believe in doctors and hospitals and their abilities and expertise for saving lives! I just don't believe that birth needs to start there. But you can bet if I end up with a patient who needs antibiotics, I will send her to a doctor for a prescription, and if my client needs a c-section, I will be right there with her in the car driving to the hospital.

I should probably add that I have never been a rebel. Even as a teenager, my greatest rebellion was sneaking my mother's romance novels out of the "secret" box in the garage and reading the sexy scenes in my closet with the door closed. I don't feel like flying in the face of medical practice or anything like that. I just think that women deserve better than to be stuck with an induction just because they haven't delivered by 39w 6d, or a C-section because they've been in labor for 12 hours and the doctor wants to go home. I'd much rather be in the comfort of my own home when doing something as intimate as giving birth, so I believe in giving women that option. I don't understand what's wrong with giving a woman antibiotics when she has an infection that can be treated by them. Why not give a baby vitamin K? What's wrong with using Pitocin or Methergan to control a hemorrhage? Don't women deserve the best care available, even if it goes against the natural community's credos? I believe they do.

July 24, 2011 | Unregistered CommenterEmily D.

I've been reading your blog for a bit and get an overall anti UC tone, which, considering your profession and what it depends upon (women trusting in you for their care) I can understand. For that matter, I have gotten disgusted with the UC community over all for many of the reasons you site.

To the matter at hand; who does a woman trust? My personal belief is NO ONE! Everyone, myself included, has ulterior motives. People are out to prove a point, meet a need, cover their ass... the list is endless. Those ulterior motives were the biggest factor in choosing a care provider free pregnancy and birth with my 2nd child 11 years ago and most of my babies since. Does that mean I have absolutely ruled out care providers?

Oh no! My 4th child was born via c-section when nothing would convince him to move out of the oblique/posterior position he'd assumed. Who called the transfer? Me. My 5th child died and I chose to go in for an induction when the midwife I'd hired to help with prenatal care (since I was now a VBAC mom) completely abandoned me and freaked on a dead baby (no obvious cause of death, he just wasn't destined to live).

Baby #6 is happily cooking away and I'm happily planning a UC but ya know, shit happens. It happens with midwives in attendance, it happens at UCs, it happens in hospitals. Babies die. Moms die. Birth is unpredictable. The best any of us can do is make the choices we can live with the easiest. I could easily schedule a c-section and avoid all the 'risks' of labor, but then I face a whole new set of risks. I could easily hire a midwife and shift some of the burden of responsibility onto another woman, but then I take on the added risk and responsibility of having to sort through that midwives motives. I don't have the energy for that or the desire to risk my baby to cover someone else's ass. At the end of the day, I'll walk the birth journey on my own and if it all goes to hell at least I'm the only one to blame and only have to live with my personal motives and choices.

Responsibility. It's not a popular concept in our society. Women need to take responsibility for their own care, their own choices. Doesn't matter if it's an OB attended birth, a midwife attended birth or a UC. WOMEN need to be responsible. Trust no one. At least not blindly.

July 28, 2011 | Unregistered CommenterMomma2SIx

Even today German law requires the presence of a midwife at every birth, even when obstetrical care is necessary. Midwives have historically been recognized as guardians of normal birth and a necessary aspect of safe maternity care, providing laboring mothers with a vital quality of emotional support that would otherwise be absent.
http://www.sciencebasedbirth.com/safety_issues01/rosenbl3.htm
*Germany has completely integrated the midwifery model of care with obstetrics, so that mum and baby have a whole team to back them up!

Midwife required, M.D. optional – German law
http://womensmedicinebowl.com/blog/?p=90

August 3, 2011 | Unregistered CommenterOubli

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