How to refuse unnecessary procedures (U/S, doppler, manual cervical checks)

[Chrisa]

How do you refuse unnecessary procedures like ultrasounds, dopplers, and cervical checks, without damaging the relationship with the OB?

Brief background: I’m at risk for preterm labor and on weekly 17-OH progesterone shots since yesterday (week 16), and I put myself on bedrest 2 weeks ago. The nurse that gives me the shots insists on using the doppler before every shot, on top of all the other uses at my OB visits (every other week). I am all for necessary medical procedures that would save my life and my baby’s. However, doctors already said that regardless of what all these checks show (short of the heartbeat stopping), there would be no change in my care, so what’s the use?

My first OB fired me last week, and suspect my – politely – refusing these procedures had something to do with it.

I transferred my care to a wonderful OB, and can’t afford to be fired by him at a critical point in my pregnancy. I would appreciate any advice from health professionals or mothers who have been successful in turning down unnecessary procedures without getting OBs irritated.

[alicewyf]

Refusing the cervical checks I can understand, especially during labor, but since you are at risk for preterm labor it is essential that the OB be able to check your cervical length occasionally via ultrasound. I say this as someone else who is at risk for preterm labor, among other complications (bicornuate uterus) and has been on progesterone supplementation until very recently (I'm 32 weeks). I could also see asking for no doppler use after the baby is moving around a lot and you don't really need to know its heartrate to know it is okay. My OB literally uses the doppler for five-ten seconds at my appointments now, and I don't have a problem with that, but if I didn't want it, he wouldn't blink an eye as long as I'm feeling regular movement.

I've only had two ultrasounds and expect to have one more before I give birth. There are plenty of people with healthy normal pregnancies who have had way more than that. I consider myself lucky considering my circumstances.

I am all for 100% natural, no ultrasounds or anything for people who aren't at risk for preterm labor or have any other pregnancy complications. It used to piss me off royally that that would never be me. I did have a 100% natural labor and birth with my daughter, and after that I realized I did the best with what I had, and still managed to keep her safe.

I hope you find a solution that works for you.
 

[Chrisa]

Thank you for replying Alice. 

I went through preterm labor last year (idiopathic, had a cervical check the week before) and lost the baby. Obviously, I wouldn't want that again. When I went to the hospital then, my cervix was 2.5 cm, no funneling.

CL is not a good predictor for me, I don't have an incompetent cervix; my problem is uterine irritability/ contractions, which I'm already having since week 13. Plus:

- doctors (regular and high-risk OBs) were very clear they would not intervene to stop contractions/ preterm labor before viability.

- cervical checks can aggravate uterine irritability, possibly triggering preterm labor (I'm always extra crampy after one).

- I'm already on bedrest and started progesterone injections. There is nothing else anyone can do at this point.

For these reasons, I don't see the risk of cervical checks outweighing the benefits for at least 7 more weeks, and that's why I want to avoid them..

[alicewyf]

I see where you are coming from, totally. Are you on any meds to relax your uterus? I also have a mild case of irritable uterus (oddly it was WAY worse with my daughter) and I seem to be able to control it with TONS of water/ rest/ occasional use of false unicorn tincture. The only time it got bad and I was hospitalized was when I was very, very sick with a stomach flu when 22ish weeks pregnant with my daughter, and I could not keep fluids down. I had contractions but they stopped them with lots of IV fluids. I am not sure how early they could start something like magnesium sulfate?

I would be annoyed that they would not try to stop labor before 24 weeks. They do for moms of multiples all the time. I'm not sure how early they usually start, but still.

I guess as far as the cervical checks go, I'd just be honest with your doc and ask why they are doing them at all, when they could get the same, probably more accurate result, less risky, with a quick ultrasound. If it were me I would want at least some monitoring so that I could get a cerclage if needed. I have not had a manual cervical check at all this pregnancy and probably won't for at least another month, if then. I know our situations are not exactly the same, but that is really odd to me.

[Chrisa]

Thanks for understanding, Alice. I will ask the Dr. for no checks until after 20 weeks, and even then for U/S checks only.

Drs won't do a cerclage on me - they said contractions will tear the cervix. Magnesium sulfate is no longer used around here at all; nor do they use any other tocolytic treatment (such as terbutaline, Procardia), before viability. Three different practices (1 high-risk OB and 2 regular OBs) told me the same thing.

Already drinking a gal water/ day, on bed rest, taking cramp bark/ black haw/ false unicorn, magnesium supplements, and literally doing everything I can to hold this baby in.

[alicewyf]

I just thought of something Chrissa. My midwives with my daughter expected me to go into labor way, way earlier than I did based on how dilated and effaced I was when I did get my cervical checks. They told me "any day" for like two weeks before I actually gave birth--at 40 weeks on the nose. During labor my daughter's bag of waters did not break (they tried to get me to let them break it, but I said no) until she crowned. They later said that probably the only reason I had made it to 40 weeks with my particular issues was because I had a really, really strong bag of waters. Then they asked me if I was loading up on vitamin C. I honestly don't remember too much about my diet with my daughter, but maybe vitamin C supplementation could be something to look into to strengthen your membranes?

[Just1More]

I've never had a high risk pregnancy...so I don't know how well this would go...

But, in general, I've found the best way to play the doctor game is to play dumb.  You can space out stuff quite a bit by first (with a sort of humbled, concerned type of tone) asking if there is any danger to the baby today?  Why do they want to check (or whatever else) right now?  Could you think about it until the next appointment?   The whole time keeping your tone and concerns sounding like you totally trust them and plan to do exactly what they say.  Use the "want to ask my dh" or "need to have my dh here" liberally to stall.

Just keep playing alone, biding time, asking questions, asking for time to "think about it" or "talk to my dh" or whatever.  Some (all?) of the stuff they want to do is probably helpful to you at some point, but maybe you can space it out and get fewer checks overall with this method.

[Sol_y_Paz]

Our situations are not the same but I am high risk and am in the doctor's office a lot and have been to the hospital more than once as well for problems.  I am on shots and do not have to have a doppler before each and every shot, actually that has never happened.  I do have the doppler but not at every appointment and if it is done it is at the very end of the appointment.  But I don't mind the doppler because I love hearing the heart beat and it is very quick.  Is it possible a nurse friend, DH, someone else you know, or your GP's office give you the shots on your week off from the doctor?  Or can you take the other form so you can do it yourself on your off week? Also frequent manual cervical checks can introduce bacteria per my doctor so not all doctors think they are needed in high risk cases.  I agree with alice a quick U/S is less risk when it comes to that particular situation, not sure in your case given the details you have provided and the fact I am not a doctor.  I do hope your new OB works out for you and I am sorry for your previous loss.  It wouldn't hurt to consult a doctor in fetal maternal med given your history just to get their opinion.  

[cristeen]

I would have a frank conversation with your OB.  Because that's really the best way to get it out there.  Let them know that you're feeling very over-medicalized, and that since they're not going to DO anything with the information at this point, you'd really rather avoid the exams.  Don't go on the attack, just let them know that you're really feeling like you're losing the ability to enjoy this pregnancy because of the constant tests and exams that they have told you will have no effect on anything.  Ask what tests/exams can be avoided, which ones are optional and which ones really are necessary.  Honestly, if the OB is as great as you seem to think, that shouldn't get their back up.  They may let you know that certain things are required to cover their own back-sides, or that certain procedures are giving them particular information that they actually do need for your continued care.  But opening the conversation respectfully with your OB (not the nurse, not the assisant), shouldn't be an issue.  And if it is, then that's not such a wonderful doctor after all, and you're better off knowing that now. 

[phathui5]

If the nurse doesn't have her own fetoscope, you could provide one for her to use at appointments.

[Chrisa]

Thank you all for the advice.

SolYPaz, I am already under the care of a high-risk (a.k.a. MFM/ perinatologist) who co-manages my case with my primary, regular OB. I heard the same thing about cervical checks, and that's another reason I want to avoid them for now.

 

I have a fetoscope, but it's too early to use at 16 weeks; I can feel fetal movement, so I know the baby is OK.

 

Alice, I am taking Vitamin C in addition to the prenatal (can you tell I'm trying everything? :). Although PROM was not my issue before (my membranes ruptured after I was dilated, and 10 minutes before my son was born), it's great to hear that in your case it helped carry to term!

 

Cristeen, I really like your advice, and I hope I find the right words when talking with the new OB. My next appt with him is in two weeks. This morning I summoned my nerves and  called the old practice (the one that dumped me), and that doctor agreed to waive the requirement of Doppler monitoring with every Progesterone injection (since they placed the order with the home care service, the waiver had to come from them). 

[amymccabe]

I'm wrestling with this myself.

In my first pregnancy I had Hyperemesis Gravidarum.  I was sick before I even missed my period and remained sick until the placenta came out.  I was on two different medications and was still very sick throughout my pregnancy.

So, no surprise that didn't tolerate the GD screening.  Since I couldn't do it, they said they'd have to assume I had GD and tried to "treat" me.  That was mainly by having me test my blood four times a day and try to make me eat more protein and less carbs.  The only thing was, with my HG, I wasn't able to tolerate protein.  I wasn't able to eat more than starches and carbs and some veggies.  Their attempts to "control" my possible gestational diabetes only made my hyperemesis worse and worse.  Having only started to put on weight at that point, my weight plateaued then declined in my third trimester.  Then they kept fussing that the baby would be HUGE!  Probably too big already!  Maybe we should induce!

My blood-sugar numbers were never high; even they admitted I was in a low risk category and my big baby (not induced and a little late) was a whooping 6 pounds, 14 ounces.

This was also all complicated by the fact that I had to see all of five midwives/doctors at the practice during the pregnancy.  Some (generally the midwives) thought I was fine.  The two doctors saw Huge Medical Issues that never materialized.

I'm not planning to get pregnant yet, but I've already sat down and talked to the midwife that delivered.  She said they won't kick me out for refusing tests.  That being said, I'm going to make a point of seeing the doctors early on then only seeing the midwives.  I know I'm refusing the GD test and all things GD (diet, testing blood sugars) if I'm sick with HG again, since "treatment" hurt my health.

[anj_rn]

I would suggest an honest approach.  Sit down with the OB and explain what you understand of the process (no stopping labor etc).  Tell the OB, that since the treatment will not change until the fetus reaches viability, you would like to avoid these procedures for now.  Be sure to indicate you woill be willing to discuss adding them back in once the fetus is viable and the results might change treatment.  Docs get scared when they hear no medical tests or interventions, make sure that you explain that you only want what is absolutely necessary.  Then as things progress, do not be afraid to ask why something is necessary.

As for the mom with HEG, I had it with both pregnancies, and could never drink the juice.  My OB (I had been moved up from my midwife by then) had me monitor my BS 3 times a day for a week.  Once those were fine, she left me alone.  With my second they gave me jelly beans instaed of the juice and I managed to keep those down.

[Quinalla]

I agree, have a frank conversation where you ask them about why they are doing certain procedures. So many things become so routine for OBs and other doctors that sometimes I think they forget why they are doing them. I am with you that I don't want them doing something just because, if they have a good reason, then that's fine with me, but if they are just gathering information that regardless of the information they won't do anything, I too don't see the point. And especially in your case with the cervical checks as they sound like they are a risk for you! But yeah, I try to phrase things like that very respectfully and that I know they have my best interests at heart, but maybe XYZ isn't necessary. And often it works best to ask questions and let them explain it to you so they come around to the conclusion themselves instead of presenting them with your already formed conclusion.

[myjewel]

your question is excellent but complicated by your status as 'at risk', which most of the other responders addressed.  For the other pregnant moms who are not at risk but are having all kinds of unnecessary procedures foisted upon them I think the operative word in your consideration is "relationship".  If you are in a relationship with someone who is controlling or manipulative or browbeating....the relationship is already damaged and then the question is why would you stay in it?  The culture of birth in this country will never ever change until women take responsibility for how and with whom they are in relationship with regarding their births.

[jenrose]

I always preface things with doctors with, "I don't mind doing tests and checks when there's something we can do with the information learned, but if there is no potential for treatment, I am not willing to put myself or my baby through the test."

With my second pregnancy, immediately after a miscarriage, I knew there was no circumstance under which I would be willing to terminate that pregnancy. So at 10 weeks I started bleeding, and was having panic attacks that I was losing the baby, so we went in for an ultrasound. They were about to do a full in depth NT scan, and I said, "No, I want to know if the heart is beating, and if you can see why I'm bleeding, and that's it. Keep it to the minimum possible."

And they did. And we did no more major testing, not even GD, though I did test my blood sugar with a home monitor a few times (it was always low).

MY daughter was born with a chromosome disorder. I love her dearly but could not do another child with a major chromosome disorder, I don't have the energy or health for it.

So with my third, terminating for a major defect was on the table, was actually something we discussed before we were willing to get pregnant at all, and we did quite a lot of testing... but knowing my blood sugar tends to be ridiculously stable in pregnancy, and that I react badly to massive sugar boluses, I declined the test but said I'd be willing to do spot checks, so the perinatologist gave me a testing schedule.. and as soon as we disocvered that my blood sugar  goes up a whopping 10 points when I eat (even after cake...) I modified the schedule... and ended up with a perfectly average sized 41 weeker.

In labor, I asked for cervical checks and membrane sweeps early on... but when I started to push involuntarily, they asked to check me and I declined. They said, "But we don't want you to tear your cervix!" and I said, "IT will hurt me and it will not make me one bit more able to stop pushing."

So no check was done, and what do you know, he  crowned a few minutes later.

You always, always have the right to say no. But there's an art to doing it in a way that minimizes the chance of them deciding you're "one of those moms" (even though I'm totally one of "those" moms...lol!)

[Durga Yael]

I noticed you're using my art without my permission, in violation of U.S. copyright law.  This is Durga Bernhard, the illustrator who created the image you're using titled "Maternal Roots".  See it here on my website:  http://durgabernhard.com/image.php?cat=8&num=15

I understand this is probably not intentional.  You can read about copyright law here:  http://durgabernhard.com/copyright.php

Can you please tell me where you got this image?  That would be useful to know.  I'd also like to know what else you've been using it for.  You may be able to continue using it if you give me copyright/credit and provide a link to my website:  http://durgabernhard.com.

Please respond to [e-mail]

kind regards,

Durga

[Durga Yael]

hello again

My sincere apologies; I did not realize Mothering has offered this image as an avatar until now.  My art has been used without my permission many times, so I'm used to finding my images unexpectedly.  No blame. 

Durga Yael Bernhard

[momala]

I'd recommend getting a good naturopath.Some things I take with advice from mine:

freeze dried nettles

raspberry leaf in capsule form - uterine tonic

wild yam - natural form of progeterone

good luck

try to keep yourself relaxed and thinking positively,it helps