"Because she has to"

When we enter the hospital to birth our baby, we like to think we’ll be informed of all options available to us. We like to think our birth plan will be read and honored. We like to think our providers will communicate with us effectively, give us time to process our options, and accept our consent or refusal as a capable adult making decisions for their own body and baby. We like to think.

The Evidence Based Birth® Childbirth Class exists because we need skills to turn “we like to think” into “we will be heard and respected”. Advocacy is a HUGE part of what couples learn in this class and I’d like to share a simple story of what advocacy in action really looks like.

I had a client a few years ago who was prepared to have an unmedicated birth. She had no risk factors. She and her baby had been very healthy the entire pregnancy. She went into spontaneous labor in the middle of the night in her 40th week and we were all excited to “doula” this and meet her baby safely and with joy.

After laboring at home all night, we arrived to her birth facility at 7cm. She was doing amazing but was ready for a bit of relief so she started breathing Nitrous Oxide (aka laughing gas) through a mask while the nurses completed their admission. I encouraged her partner to lie down on the sofa to grab a quick cat-nap as their baby was on their way. I was fresher than he was and I told him it was now or never. Thirty seconds later, you just heard “zzzzzzzz” from the sofa. I was right by her side. She was safe while he rested.

Our admission RN was new and she had a preceptor looming in the corner and charting on the computer while the trainee completed our intake. The trainee RN was lovely. She got down to the level of my client to speak with her. She asked permission to touch her and explained what she was doing. Her preceptor was a more ominous presence in the corner, clearly irritated that her trainee was taking so long. Showing respect is not a speedy process. It requires asking permission and waiting for an answer, and sometimes that takes a few contractions. This trainee was doing it right and I shuddered to think what our experience would have been like had we only had the more seasoned RN. I showed some love (another advocacy skill) to the trainee and thanked her for the gentle, empathetic care she was showing my client. Her smile of appreciation told me she wasn’t getting the same kind of love from her preceptor.

They both left the room and came back with the trainee RN holding a bag of IV fluids and tubing. My client had consented to having a saline lock placed, which is simple IV access, but not to hooking up and running IV fluids. Her baby looked beautiful (remember she had a seasoned RN who was raised by midwives as her doula - a fierce combination) and there was nothing in her course of labor that warranted extra IV fluids. My client was drinking well and holding everything down. Her labor was moving along nicely and baby looked great.

As the trainee RN walked over to sheepishly hang this bag on the IV pole, I leaned in to speak loudly over white noise of the Nitrous Oxide delivery device. I calmly told my client, “It looks like they’re getting ready to hang IV fluids. I know you didn’t want IV fluids. Do you consent?” My client took off the mask for 2 seconds and said “No!”. She put the mask back on and was back in labor land in an instant. The new RN looked at her preceptor and the preceptor glared back at her, over her glasses, with a condescending gaze that said “just do it”. As the new RN started fishing around for my client’s saline lock, I reminded my client that the RN was trying to find her saline lock to hook up the IV fluids. My client pulled the mask away again, said “No” - again, pulled her arm under her body, effectively hiding the saline lock from the RN, put the mask back on her face and went back to labor land. I smiled a huge, proud smile. Even at 7cm, she was making her own choices, her way.

The new RN looked back to the preceptor again, as did I. I stated that my client had on her birth plan that she did not want IV fluids unless it was medically necessary. As an RN, I knew IV fluids were not medically indicated in this labor. I respectfully asked the preceptor, without showing my cards that I was an RN too, what the indication was for needing IV fluids. I told them I’d be happy to facilitate a discussion on this point with a good answer.

The preceptor didn’t have one. Her answer, glaring over her glasses and making eye-contact with me for the first time as I glared over my glasses back at her (it was like the silent battle of the seasoned nurses), was simply, “Because she has to. The doctor ordered it.” Hmmmm…. The doctor ordered it. We hadn’t even seen the whites of the doctor’s eyes. No assessment from this person had occurred yet. They weren’t even in the hospital but at home waiting to be called when the head was on the perineum. There was nothing about this “order" that demonstrated individualized care. This was part of this doctor’s standard orders for everyone. My client was on an assembly line and the conveyor belt had stopped at the “start the IV fluids” portion of the admission process, and here we were.

I looked back down at my client and got close to her head to tell her calmly “The nurse is telling us you have to have continuous IV fluids because the doctor ordered it. Do you give consent?” She glared at me one last time, pulled her mask away from her face, and I braced myself as she strung together a string of expletives, directed at the preceptor, followed by a firmly stated “NO!” for the third and last time. I looked up at her new RN and the preceptor RN, shrugged my shoulders, lifted my hands in a simple gesture and stated factually “She said no.” 🤷🏼‍♀️

This gesture showed empathy to the nurses. I don’t have any control over her answers either. Nurses are often caught in the middle what the doctor wants, what the hospital policy dictates, and what the patient wants. None of us have any control over what the birthing person wants and doesn’t want. It puts her support team on the same playing field with her nurses and demonstrates who’s really in control. The person in labor. Period.

Without knowing that we have a right to refuse ANY intervention, sadly the patient is often the easier one to push than the physician, the nurse manager, or the lawyer in the distant tower. Nurses must offer care within the guidelines of hospital policy and follow doctors orders. Can they question an order? Absolutely, and some would have taken that first “no” as the final answer and would have reported back to the provider that the patient refused IV fluids. But in our case, the trainee RN had zero power and the preceptor RN had no interest in telling the physician that the patient refused his orders. She would have rather forced the issue with my client vs. tell the doctor “she said no”.

While we’d like to think that our nurses will help us know when hospital policies are not to our benefit, that simply does not happen. Nurses are stuck in the middle of those who think they have power over the birthing person - the physicians, lawyers, and administrators - and the people who actually do have the power, the patient. Yes, the birthing person absolutely has the most power, they just don’t know it because it’s the best kept secret in maternity care. The advocacy skills you learn in the EBB® Childbirth Class take the patient off the bottom of this top-down hierarchy of care and gives them the tools to level the playing field.

My client knew her rights after taking the EBB® Childbirth Class. She knew how to advocate for herself and she also knew there may come a time where she wouldn’t be as effective at it and would need to lean into her support team. They hired me because they knew her partner may not feel as comfortable doing it for her when she couldn’t do it for herself. I’m confident that without my being there, that IV would have been connected and she would have noticed at some point but labor would have likely had her deciding to not fight the battle. Her partner admitted he would have caved at the answer of “because she has to”. Instead, we used the advocacy skills we discussed ahead of time and she played the game perfectly. She knew what I was doing with her and she knew her “no” would be enough with someone else helping to amplify her voice.

We can have all of the evidence in the world to want this and avoid that. But when the game is played, we’re frequently hit with tackles that we never saw coming because our providers are skilled at this game and we are not. Policies and doctor’s orders seem like rules that cannot be broken. My client knew “doctors orders” wasn’t a medical diagnosis requiring an intervention. She knew that hospital policy was a fancy term for “we’re not giving you a choice”. She knew all about the typical bundle of care millions of women receive every day on the assembly line of childbirth. She also knew her patient rights and that she had the right to refuse any procedure she did not want.

I should mention that we didn’t see that preceptor RN in our room again. Just the new trainee who was the perfect person to support my client’s eventual unmedicated birth. The preceptor was present only to show her trainee how to put her foot down with doulas… but I didn’t have the power either. My client had it all and she knew the buck stopped there. Interestingly, the doctor never said a word about not having IV fluids running when they arrived to catch the baby. Hmmmmm, I guess it wasn’t that important after all.

My client was so incredibly proud of herself for saying “no” in labor. A 2-letter word, stated firmly three times was all it took for her to set the tone of how things were going to go. The rest was all her, and she rocked it! When the evidence isn’t enough, when our care plan is disregarded, we have nothing left but advocacy skills. The EBB® Childbirth Class covers all of it and you, too can advocate with confidence, just like my client did. Partners leave with knowledge of the labor process, the evidence, indications for medical interventions, areas where non-medical alternatives can be utilized, and most importantly, how to advocate with the calm respect that this moment in your life requires.

Knowing what can happen in childbirth is the first step. Knowing what you want in childbirth is the next step. Knowing how to get it is the advocacy step that EBB® does better than anyone else. Sign up for a class and see for yourself.