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Entries in patient advocacy (3)

Tuesday
Jan042011

Banning Cameras at Birth

I'm sure most of us have already weighed in on Meritus Medical Center's ban on cameras (of any kind) in labor and delivery, allowed to turn on no earlier than five minutes after the birth.

"On Nov. 1, Meritus Medical Center implemented a policy prohibiting video, film and still photography of deliveries until five minutes after birth. The change is intended to protect patient privacy and reduce potential staff distractions, said Jody Bishop, administrative director of the department that includes the hospital's birthing center."

They go on to blah blah blah about patient safety -"The intent is for the physicians and midwives and staff to be able to focus on the delivery itself and on the safety of the mom and baby."

Yeah, like anyone believes that.

Today, I finally read an article that included commentary by a medical malpractice attorney. Brian McKeen says (on ABCnews.com):

"There's no question in my mind or in the minds of other colleagues who I've worked with on the obstetrical side that hospitals are doing this so as not to have a piece of evidence generated that can be used against them in a court of law," McKeen told ABC World News. "They do it to hide the truth."

"...video and photos from a delivery can help in deciding a medical malpractice case.

"It may show that the physician complied with the standard care and engaged in all the appropriate maneuvers, or it may show the physician did not engage in the appropriate maneuvers and or used excessive force and caused the birth injury," he said.

McKeen said that if a patient isn't permitted to photograph or videotape a birth when they want to, they should find another doctor.

I agree.

While I suspect most people don't want to be filmed while they work, I'd venture a guess to say most people are taped on their jobs. Might being taped change one's behavior? Isn't that something many/most of us would like to see in hospital births?

Can you imagine?!

Obstetric violence would plummet. Strong-arming would virtually disappear. Snotty comments would be replayed on YouTube.

Women might actually be treated humanely.

Imagine that.

Wednesday
Dec222010

Charting: Whose Truth?

A brilliant piece came out December 2, 2010 in Birth Sense. “Five Reasons Your Doctor/Hospital/Midwife May Not Want You to See Your Medical Records,” caused a flood of trying-to-read-my-chart stories to fall from my brain into a jumble of scribbled-on papers, too many of which making no sense whatsoever. 

When my niece was entering Medical School, she had to present about a trillion pieces of documentation, one of which was her entire life’s medical records. Of course, we pored through them, reading her history through the eyes of care providers. While many of the entries were barely legible, one doctor in particular wrote in a hand that knew nothing but straight lines with an occasional twitch of the pen upwards. The overseeing committee considered sending her back to the HMO to find the doctor and ask him what he’d written. The notation was from ten years ago! 

I’ve read charts and written in charts for many years, even studying charting manuals to make sure my notations were medically and legally accurate. (A couple of books I've used were Mosby's Surefire Documentation: How, What, and When Nurses Need to Document and Charting Made Incredibly Easy.) But, through reading what other health care providers have written, I am continually reminded that much of charting is quite subjective. This fact alone should (in my opinion) comfort many a woman crying over the stupid things someone wrote in her chart. All sorts of things can affect what the provider (nurse, doctor, midwife, chiropractor, etc.) chooses to document. If they’re having a crappy day, their attitude colors the descriptions of what’s in front of them. A happy midwife might write (in shorthand, however): Patient concerned about weight gain. Whereas a cranky midwife might write: Weight gain excessive; counseled patient. All sorts of life situations can affect the tone of a provider’s notes: marital satisfaction, health, ingrained beliefs about certain races or gender… even religious prejudices or, what many of us encounter, disagreeing with the doctor’s advice. 

My own kids’ records are a study in annoyance on the part of the nurses (mostly). I would not let them take my kids’ temperature rectally; this was the standard of care in the 80’s. All over their charts: Mother refuses rectal temp. Sometimes with a giant exclamation point to reiterate their disgust that I dare defy their protocol… and near-shoving me, trying to get me to do what they wanted to do. I didn’t care. I wasn’t going to risk having my children’s bowels perforated. Tough if you don’t like it (was my thinking). 

When it comes to our maternity records, it can be scary to see what someone thought about us, how they perceived our choices and actions. Reading cold observations like “Patient refuses to take prenatal vitamins” can be disconcerting when the reality was the ones you tried made you throw up. 

The worry and fear can really take hold when we order our prenatal, labor and delivery and postpartum records. Reading what you lived through can be surreal; what’s on the paper all too often totally disagrees with a woman’s memory of her birth. What annoys me greatly is the medical record is considered The Truth, is used in court as the Be All and End All of what happened at the birth. Can I tell you the crap I’ve read “documenting” a birth I’d doula’d and knew the details of very clearly? I’ve seen exaggerations of a woman’s pain level, nasty comments about a family member’s behavior, mis-timings of when a mother started pushing and more. What must a mom think reading her chart without someone to let her know, “This is bullshit.”? 

Birth Sense’s post gives examples of the challenges women face when they want to get their records… how people lie about who the chart belongs to, charge them huge fees to obtain their records (I had to pay $50 to get my records from Tristan’s hospital birth) and women having their charts physically ripped out of their hands. I encourage women to find a friendly midwife who will order your records for you and perhaps going over them with you (for a consult fee, of course). If you want your records without the consult, no problem; they are your records. 

When you get your chart, please remember the subjectivity of what’s written in there. Post-cesarean moms in particular half close their eyes as they read what’s written about why they had a surgical delivery. Over and over I’ve heard moms tell me, “But they said <fill in the blank>! They didn’t tell me there was <fill in the blank>.” The chart can reassure a mother wanting to have a VBAC (was there a single or double layer suture [which, by the way, isn’t charted quite often, so the assumption is it was a single layer suture… the conservative route], was the baby acynclitic or was there a nuchal hand… variations not likely to repeat with the next baby. The chart can also bring the memory of a birth crisis crashing over a woman’s body and mind. If there were near-death experiences with the baby or dramatic hemorrhages for the mom (for example), reading can mean re-living; take exquisite care of your Self as you open the folder. 

Along with the “the doctor didn’t tell me that,” comes “They are wrong!” Twice I’ve seen the gender of the baby written incorrectly. Not that it’s funny, but I chuckle thinking about that chart being used as an exhibit in court; is it an accurate account of what happened? Or was the person that was too oblivious to note the gender correctly also too oblivious to record the mother’s overdose of pain meds. 

So, if you do get your chart, as you read, take what’s said in there with a salt lick (as opposed to a grain of salt). If you find notations that are flat out lies, you can petition to get the chart amended. If you don’t do that, you might not be able to convince another provider that what’s written is, in fact, false. But, even if the exaggeration/lie/mistake remains in there, at least you know the truth and a sympathetic provider will certainly take your words under advisement. 

All of this does not imply that every chart has patent lies or glaring mistakes written in them. We’re taught to be as objective as possible, but, as humans, that isn’t always possible. I'd even say the great majority of records I've read have aligned with what the mom recounts as well. And there are times when mom's memory differs from the chart because the memory was out of context to the whole picture and once it's put into context, the woman's able to revise her knowledge about her own case.

But it can be healing for women to hold their charts in their hands. Empowering, even. So, if you're ready, order your chart, read it and learn what you can about your specific case. Ask questions if you don’t understand something and then move forward with the new knowledge you have about your Self and your baby's birth. As is often said, "Knowledge is Power!"

Me, charting after a birth. Photo by Nova Bella de Lovely. 

Sunday
Nov072010

Transition

The word “transition,” to most of us reading this, brings up images of laboring women, typically, seven to ten centimeters dilated (or at least that’s what the textbooks say), each woman working through her transition. Some moms breathe heavily, others moan… and, all too often, many are numbed from nipples to toes, virtually unaware of the mechanical changes going on inside. I find it takes a fairly crunchy woman to push deeper to define the word in a more literal way, acknowledging the obvious; a woman moving from one stage of her life (Madonna/Non-mother) to another (Mother). Transition, as we know it, does not have an absolute demarcation point. There is no stick you can pee on or blood test you can do that says, “I’m in transition.” It is more fluid than the medical world is able/willing to admit. 

Our lives are full of transitions, often celebrated as Rites of Passage. Christenings, birthdays, getting a driver’s license… old enough to vote… are all a part of our culture here in America. But, as we also know, not all Rites of Passage are joyful and pleasant. Divorce, losing a job and, all too often now, going bankrupt are some of the difficult and painful transitions. 

And then there is death. The transition none of us escapes. Death is a measurable, quantifiable end to life’s continual transition that began with birth (maybe earlier?) and ends as someone states the body’s functioning has ceased. But what of a life quickly lost? That person’s final transition might have been imperceptible, similar to some women’s labor transitions. For those that are ill, transition can be slow and painful, requiring the help of those around them to make it through to the other side. 

The parallels between birth and death have long been made in poetry, literature, songs and throughout oral histories. I’ve had the opportunity to experience those parallels first-hand; the experiences are divinely cherished. 

In the 80’s, I was present during the transition period of several men with AIDS, only rarely present for the actual moment of death. I doula’d these men, many of whom had been abandoned by their families, telling them stories, holding their hands and using cool cloths to wipe the fever’d sweat from their foreheads. I know that being with these dying men gave me many lessons I would need later as a doula and a midwife. Of course, I didn’t know that then. 

My children’s grandmother, Abuela, is dying. She has a brain tumor and it is slowly taking over her body, altering functions we generally take for granted. Abuela has been one of those women who were always working –for the pure joy of doing so. The last of sixteen kids, she outlived every other person in her birth family. We knew it was because she loved living! Abuela, also my former mother-in-law, was a chef… an amazing chef, creating dishes from thin air, carving great pieces of art out of fruits and vegetables and, oh. my. god. –made the best peanut butter cookies on the planet. I have never had a peanut butter cookie as luscious as the ones Abuela made. (I’m salivating even remembering… and it’s been 28 years since I’ve had one!) Her hands were magical around food and she was never without a laughing smile on her face. I love(d) her as if she were my own mother. Luckily, she loved me, too. Even after her son and I divorced, her face lit up every time I came to visit; my own face did the same.  

My former husband’s family is from the Dominican Republic, so Spanish is the first language. Abuela, working in America, learned a decent command of the English language. Her husband (Papa), spoke Spanish-only to his dying day. But, Abuela’s thick accent often had people saying, “Excuse me?” so she’d repeat what she was trying to convey. I didn’t learn enough Spanish to communicate easily with her until many years after the divorce, but once I could speak more, I loved being able to talk with her about her life. 

We in the homebirth/natural birth circles are hyper-aware of institutions and how they interact with individuals; there really isn’t a place for individuality. For a variety of reasons, Abuela is in a nursing home, far from my kids and even her son; she is now much too ill to move without it killing her. So, my children and their father are taking turns going down to Miami and spending several days at a time with her. A family member also hired a nanny (of sorts) to keep her company during the day. The nanny’s presence has been a god-send to my mother-in-law. Even still, as my kids make their trek and sit their vigil, they are disturbed by the thoughtless “care” their grandmother is receiving, the nurse’s aids yacking about soap operas, looking over Abuela as they carelessly change her sheets or clothes. My daughter Aimee was especially upset as Abuela cried out when the aid hurt her and didn’t even acknowledge it. (The supervisor was notified and the aid reprimanded, but that doesn’t change the pain Abuela experienced.) 

I know so many of you who had cesareans talk sadly (or angrily) about the surgeon and the operating room team blithely talking about the latest football game or where to go for dinner as your babies were coming into the world. It’s just sad when a woman has to put on her birth plan “Please do not talk about outside activities. Please stay present with my baby’s birth.” It’s equally sad, even abhorrent, that people responsible for doula-ing the dying can be so callous towards their charges. I wanted to slap that bitch (from 3100 miles away) for hurting my mother-in-law. 

Instead, I taught Aimee a skill that will serve her forever. I told her how to stop someone who’s blabbing in their own world, yanking them back into the here and now and remind them to see the person they are touching as a holy soul. So many of us sit idly by as corporations and institutions man-handle us –or worse, our children, until we have that pivotal experience where we snap and say, “What the hell are you doing to me?! STOP IT!” It’s a toss up which is worse, learning the skill while helping someone else or learning it because of what was being done to you. 

And yes, being in the moment. In my Birth as Yoga post, I write: 

I am her (the laboring mother’s) sentry, quietly “holding the space”… sitting with a clarity I don’t have in the outside/real world. This attuned place keeps me alert, even when I am exhausted; I note time passing, yet it is never anything but right now that exists. 

There is nothing more in the moment than birth and death. Each zeros in at the speed of light, pin-pointing the exact nanosecond of passing from one place into another. Even for witnesses (the stupid OBs notwithstanding), the moment is imprinted in the mind and heart forever. But it is a moment in time that can seem suspended, lingering in the air, waiting for the breath-work to begin/finish what it is going to do. 

(I know the agony of waiting for a baby to breathe, of working to get a baby to breathe… time crawls and flies all at the same time. I have not ever had a baby die in my hands and cannot imagine that pain, but suspect the anticipation/begging the baby to breathe must never end. This sort of time must be in another plane of reality altogether.) 

When I talked to Aimee about Abuela’s need for remaining in the moment, she was already completely understanding the concept and had been holding that space ever since she arrived. It can be so easy to sit with the dying and cry, being sad for the life they are leaving. 

I encouraged Aimee to tell her stories, happy, loving stories, whether they included Abuela or not. Aimee’s concern was that her Spanish wasn’t good enough and she was wishing for someone to translate. I smiled, totally knowing this feeling with birthing women when my Spanish was inadequate for the role. But, it didn’t take long for me to realize when love is the gift, verbal language is no longer necessary… and if words are spoken, they are translated by the heart/soul, creating a complete understanding between the two “speaking.” 

Surpassing even the language barriers, laboring transition, as well as death transition, can include an inability to communicate. The brain tumor has made communicating extremely difficult for Abuela, her speech affected, her hands curled so she is no longer able to write. This is when other modes of communication can move beyond the spoken word; the gentle touch on the arm, loving foot massages, wiping the brow/spittle from the forehead/mouth. We witness bodily functions give way and note that modesty disappears for many women in birth and, as those who attend to the dying know, on the cusp of death as well. It is imperative for birth/death workers to never be grossed out by poop, vomit or blood. Disgust is a mean and useless emotion to the birthing/dying person. None of us wants to be repulsive to someone in charge of our care. 

I’ve seen family members (mothers of the laboring woman most often) and even new doulas feel sorry for the woman in transition. What might better be empathy has twisted into sympathy. Sympathy rarely makes a mom feel better. I’ve seen a mom lose faith in her body’s abilities when those around her are morose and sad for her laboring state. I’ve also seen women buoyed by the positive, affirming words and actions of those around her. It has to be nicer to see people smiling and cheering you on rather than someone sitting, staring and wringing their hands with worry. It’s one reason we discuss who will be at the birth and what their roles will be. If a woman knows someone is going to struggle with the process, it’s good to either work with that person and address their concerns or, as is the case for some women, not have that person at the birth at all. 

With death, even if someone is uncomfortable, it can be a time to face the discomfort, suck it up, so they can pay homage to their friend or relative leaving the earth; in birth, they can be excused from the event. But, sitting with a dying person, we face our own mortality and that can be unbelievably difficult for some (most?) people in our culture where death, like birth, is hidden behind institutionalized walls and attended to by people in white scrubs. When we keep the dying company, we have seconds, minutes, hours and even days (if we’re lucky) where we hear nothing more than the breathing in and out of our ill or old loved one. Yet, inside our heads, we are far from alone… it is anything but silent. Our inner dialogue works with our situation, making sense of things, organizing thoughts into “What I need to do/What I want to do/What I will do” for the rest or our lives’ unfolding. Being in those last moments, being supremely present, we learn/realize what the crucially important parts of our lives are and figure out where to go from here. 

I want to die at home. I do not want to die amongst sterile (HAHA) machines and even more sterile attendants. I want to lie in my bed… my loving, soft, cooing family around me. I want to die in the same manner as I love to give birth -supported and believed. I want to smell my own pillows, feel my dogs licking my hands, feel Sarah kissing my face. I want to melt into tomorrow, leaving no regrets for what I did today. 

As George Strait gently sings: 

Just like it took my breath when she was born
Just like it took my breath away when dad took his last that morn

Life’s not the breaths you take
The breathing in and out
That gets you through the day
Life’s not the breaths you take
But the moments that take your breath away

Abuela & Aimee - November 4, 2010