How much say does a DR have on a mom's delivery position? - Mothering Forums
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#1 of 47 Old 04-22-2009, 02:46 AM - Thread Starter
 
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I am a Doula-in-training, attending my 3rd hospital birth. The mom wants to have a epidural-free birth, and would like to deliver in any position that feels right to her. Her OB has told her that she MUST deliver lying in bed, and is very pro-epi.

The mom has asked that I act as an advocate on her behalf in these matters, which I'm not exactly sure how to go about doing.

Can an OB ever dictate what position a mom delivers in? I'm thinking no...but I've has 3 homebirths and was able to do whatever I wanted, when I wanted it. The other 2 hospital births I attended had OB's that weren't even in the room until the baby was crowning, and one mom was already in the bed.

Can anyone shed some light on this for me, and maybe advise how much I should say or do on the Mom's behalf? I don't want a tense situation in the delivery room, but I want to do all I can for the mom.
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#2 of 47 Old 04-22-2009, 03:29 AM
 
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I am a Doula-in-training, attending my 3rd hospital birth. The mom wants to have a epidural-free birth, and would like to deliver in any position that feels right to her. Her OB has told her that she MUST deliver lying in bed, and is very pro-epi.

The mom has asked that I act as an advocate on her behalf in these matters, which I'm not exactly sure how to go about doing.

Can an OB ever dictate what position a mom delivers in? I'm thinking no...but I've has 3 homebirths and was able to do whatever I wanted, when I wanted it. The other 2 hospital births I attended had OB's that weren't even in the room until the baby was crowning, and one mom was already in the bed.

Can anyone shed some light on this for me, and maybe advise how much I should say or do on the Mom's behalf? I don't want a tense situation in the delivery room, but I want to do all I can for the mom.
This is a toughie. IME, the ob has a lot of say. I've had a woman in hands-and-knees and the ob came in and announced firmly that she could *not* deliver her in that position, that she had to turn over, and then had the nurse (and eventually me, to my shame) physically turning the woman over, practically mid-push.

The nurses also know what the ob on shift expect/wants. I almost never see a bed broken down, but I have seen it done before the ob even got in the room when the nurses knew that those were the standing orders.

If the ob doesn't get there until the baby's crowning, then the s/he may be forced to just catch. Earlier than that, though, and they can be pretty forceful at getting the position they want if they're so inclined. Nurses too, for that matter. (If you haven't seen a bullying nurse yet, just wait for it.)

Your client's putting you in an awkward place. She needs to understand that you cannot fight with her doctor. I usually tell my clients that I cannot speak to the doctor on their behalf, but I can help them do their own speaking. Suggest she keep talking to her doctor, encourage her to write a birth plan, and if she can convince the doc to initial it, so much the better.

The birth plan gives you the opportunity to remind your clients of what they said they wanted, and makes it more possible for you to speak directly to the staff about what they want. If you can forge a good relationship with the nurse during the labour that can help a huge amount, too. Get *her* advocating on your client's behalf and you'll be well on your way to helping your client get the birth she wants.

Another thought: if it's really going to be a battle, talk with your client about whether there are compromises that would be acceptable to her. For instance, if she wants to squat, show her how she can squat on the bed with support people on either side to hang on to. I've yet to see an ob who was willing to sit on the floor, but if you can help a woman do h&k, squatting etc on the bed, you have a chance of meeting both party's needs.

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#3 of 47 Old 04-22-2009, 04:09 AM
 
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how should it be? well it SHOULD be that the OB doesn't decide and the mom gets to decide...

realistically it doesn't work that way.

if an OB is set agianst it, it just wont happen. and she could be seen as combative if she tries it. and really? during birth is NO time to pick a fight. she needs her energy to birth, not to fight a battle about what position.

if she is that set on birthing in another position she needs to find a providor that will accomodate that. I can't stress enough - the birthing room should never be used as a the time or place to argue these things out. if it can't be settled on BEFORE the birth, she should look elsewhere.

secondly, as a doula you can only help her make these decisions... it isn't your place to try to get the OB to let her do it. that puts you in a VERY unfair place. not only is it unfair, it's unrealistic. there is no way an OB will listen to a doula about such a thing if they are set on it - likely it would only aggrivate the OB and cause more tension in the birthing room. and your client would feel let down by you.

bottom line, she needs to be working towards getting what she needs. it sounds like she has a misunderstanding about the role of a doula in the hospital birth setting. it seems she expects a lot out of you that you can't promise her and i would consider being upfront about it with her. maybe she needs ot better understand what your role is or can be for her... and what it can't be.

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#4 of 47 Old 04-22-2009, 08:50 AM
 
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A doula simply cannot be the advocate this mom is looking for. There are many things you can say during labor to help the parents advocate for themselves--reminders you can make, questions to ask 'as a reminder'--such as "we discussed your birthing in a hands and knees position, is this still something you want to try?" You can explain medical or hospital policy stuff that they might not understand, to aid in their decision making. But you cannot sound off FOR them. Only a woman and her partner is allowed this role, and I think that is for the best since it is their birth and their power to choose that is at stake.

That said, I also agree that this OB sounds like one who will not be amenable to any changes. Now the parents know that he is both pro-epi, and unwilling to catch babies in any 'alternate' position. If they are not happy with this, then rather than wasting time arguing they should be looking for a provider whose thoughts on birth are more in line with their own. It would certainly SEEM that a hired helper like an OB should be willing to serve as parents wish (at least within the scope of the OB's protocols and knowledge), but this is very rarely the case.

Further, it would be a fatal mistake to underestimate the degree of power over patients that med providers, and med institutions on the whole, are willing to exert over their clients. As TO doula points out, even she was harangued into helping exert force over a laboring patient, against her wishes and her beliefs. This is NOT AT ALL UNCOMMON for OBs and hospitals--doctors will shout at laboring women, make threats, use physical force and/or order nurses to exert physical force. YOU, as a doula, do NOT want to be put into this position. SHE as a future laboring woman, should not be going into this with eyes closed to these awful possibilities.

I can only say again--if this doc does not already practice the way the mom prefers, then she needs to find another doc--or resign herself to doing birth HIS way, for her own peace of mind. And your client needs to understand that you simply cannot be the advocate she is asking for.
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#5 of 47 Old 04-22-2009, 11:11 AM
 
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The truth is that she doesn't sound like she wants to really be responsible for her choices. I know that sounds harsh, but she is the one who gets the choose the doctor. A doula cannot save people from their own poor choices in care providers. A big part of a doula role is to point out when this just isn't going to work and then the mom needs to find a care provider who will be a better fit. It is like if a client is going to a dr with a 95% c-section rate and then figures that if she hires a doula then she will magically get the vaginal birth she wants.... it is not going to happen.

It is a rotten thing to go into a birth feeling like you need to fight. It isn't a fair position for you to be in and it isn't going to turn out the way she wants either. No one needs to have tension and argument at the time of birth. And during transition women are very open to suggestions too, even if they don't want to be. So, it is likely she will go along with what the doctor says and then be upset about it later that you didn't fight for her and what she wanted. Not at all a good situation to be in.

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#6 of 47 Old 04-22-2009, 11:14 AM
 
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She needs a different care provider.

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#7 of 47 Old 04-22-2009, 11:15 AM
 
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The truth is that she doesn't sound like she wants to really be responsible for her choices. I know that sounds harsh, but she is the one who gets the choose the doctor. A doula cannot save people from their own poor choices in care providers. A big part of a doula role is to point out when this just isn't going to work and then the mom needs to find a care provider who will be a better fit. It is like if a client is going to a dr with a 95% c-section rate and then figures that if she hires a doula then she will magically get the vaginal birth she wants.... it is not going to happen.
Keep in mind that not everyone has choices. Around here obs work in group practices and you get whoever is on call. I think we also need to help our clients understand how to work with what you've got.

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#8 of 47 Old 04-22-2009, 11:25 AM
 
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Keep in mind that not everyone has choices. Around here obs work in group practices and you get whoever is on call. I think we also need to help our clients understand how to work with what you've got.
Yes, this is true, but this sounds like a situation where it isn't the ob on call who is the problem, but the one the client has chosen to be her ob. So she has a clear indication already that things will not go the way she wants and so now would be an excellent time to explore her options more thoroughly.

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#9 of 47 Old 04-22-2009, 01:37 PM
 
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from what i've seen here, what the doctor says goes

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#10 of 47 Old 04-22-2009, 02:31 PM
 
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I'm not a birth professional but I think this mom is asking you to do something that is not in your job description. She needs to have a frank talk with her doctor ahead of time about what her expectations are. And then she needs to assign someone like her spouse/partner who actually CAN make medical decisions and speak on her behalf to do the in-hospital advocating.

You can remind her and her family about her wishes, as in, "The doctor just said she was going to do X, but you told me last week you didn't want this. Do you and your husband want to discuss this before going ahead with it?"

Sounds to me like she would do best switching providers, but depending on how soon the birth is, this may not be possible. The other option is for her to show up in the hospital and take the on-call doctor (this is actually what I ended up doing for my VBAC).

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#11 of 47 Old 04-22-2009, 05:31 PM
 
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Laura and MsBlack have both already said it so well. I also agree that in order for her to take charge and get the birth she wants, she will need to take charge and the responsibility to find a care provider that will help her to get the birth she wants. If she is not willing ot do that, there isnt a whole lot more you can do beyond you're normal doula service for her.

TO Doula- Lets hope she is not in that situation. It is systems like that that would have me running. Id rather give birth in a barn than take "who ever is on call" from a whole group of OBs I dont know. How hard.

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#12 of 47 Old 04-22-2009, 05:40 PM
 
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from what i've seen here, what the doctor says goes
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This makes me mad. I would hope the laboring woman who has HIRED an ob would get to do as she wants. It's not hurting anything, and where exactly do doctors get the idea that they can FORCE that on a woman? Seriously, where did you sign saying you agree to whatever the doctor wants? If they tried to force me out of my best position for me, I would threaten to sue anyone that touched me!
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#13 of 47 Old 04-22-2009, 06:24 PM
 
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This makes me mad. I would hope the laboring woman who has HIRED an ob would get to do as she wants. It's not hurting anything, and where exactly do doctors get the idea that they can FORCE that on a woman? Seriously, where did you sign saying you agree to whatever the doctor wants? If they tried to force me out of my best position for me, I would threaten to sue anyone that touched me!

Unfortunately most hospitals do make you sign a paper as part of your registration process that gives them (and their Dr's) full permission to do as the please and gives them the right to make medical decisions without having to ask consent in the moment. It is a standard intake form and I'm sure most moms sign it without even noticing. And most hospital make you sign it if you plan on delivering at their hospital.

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#14 of 47 Old 04-22-2009, 06:27 PM - Thread Starter
 
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Your client's putting you in an awkward place. She needs to understand that you cannot fight with her doctor. I usually tell my clients that I cannot speak to the doctor on their behalf, but I can help them do their own speaking. Suggest she keep talking to her doctor, encourage her to write a birth plan, and if she can convince the doc to initial it, so much the better.
I agree. I've told her I will not "fight," and that that is not something she wants happening in her birth room. I've encouraged her to write a birth plan, (she's working on it...she 'didn't know you could do such a thing.' ?!?!) and suggested she get the doctor to initial it. I'm afraid it won't happen tho.

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Originally Posted by hotwings640
The truth is that she doesn't sound like she wants to really be responsible for her choices.
TRUE.
She is a self-proclaimed "push-over" and really just doesn't want to be bold enough to put her foot down with her doctor. (her words) She is also 3 weeks away from her due date, and is scared and not motivated enough to search for another DR that may be more willing to work with her. So, I'm afraid she will have to get what she gets. ):

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Another thought: if it's really going to be a battle, talk with your client about whether there are compromises that would be acceptable to her. For instance, if she wants to squat, show her how she can squat on the bed with support people on either side to hang on to. I've yet to see an ob who was willing to sit on the floor, but if you can help a woman do h&k, squatting etc on the bed, you have a chance of meeting both party's needs.
We have discussed this also, and she is willing to try these alternatives, but is pretty sure the Dr won't allow it. We'll see.

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If they tried to force me out of my best position for me, I would threaten to sue anyone that touched me!
DITTO!:

Unfortunately, this is really a case of a Mom suddenly trying to educate herself weeks before her due date. I am working hard with her to answer questions and suggest reading materials and other resources; but I fear that the choice of OB was not well thought out beforehand, and that it will have a big impact on what she now wants at her birth.
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#15 of 47 Old 04-22-2009, 06:36 PM
 
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TO Doula- Lets hope she is not in that situation. It is systems like that that would have me running. Id rather give birth in a barn than take "who ever is on call" from a whole group of OBs I dont know. How hard.
Oh, it's incredibly frustrating. OBs and midwives are in such short supply that women wind up just taking what/who they can get. There is no such thing as interviewing care providers any more.

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#16 of 47 Old 04-22-2009, 07:01 PM
 
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FWIW -- I work at a relatively liberal L&D -- the best in this area as far as allowing choice for birthing. We have a group of midwives that deliver, as well as many MD's. I have been there almost a year now and have never seen anyone deliver in any position but on her back. The most deviation I have seen is a slight tilt to the side (although I have been yelled at by a provider for having a patient pushing on her side, even though the baby was OP and she had been pushing for 3 hours with no progress -- the only chance she had was if the baby turned, which I was trying to facilitate by changing position as much as possible with the epidural). Our midwives are more open to what patients want to try, and I have seen them do some pushing in hands and knees, but ultimately everyone has wound up delivering laying down. None of our MD's would even consider anything anything else.

Like the PPs said, if her provider already said no, it ain't gonna happen. They will move her. And, honestly, he really has no idea how to catch a baby in an alternate position anyway, so safety might be a concern. Probably the staff will push an epidural on her anyway, then it won't even be an issue.


Good luck...

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#17 of 47 Old 04-22-2009, 07:06 PM - Thread Starter
 
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I have been there almost a year now and have never seen anyone deliver in any position but on her back.

Like the PPs said, if her provider already said no, it ain't gonna happen. They will move her. And, honestly, he really has no idea how to catch a baby in an alternate position anyway, so safety might be a concern. Probably the staff will push an epidural on her anyway, then it won't even be an issue.
Why is this? They DO know that different positions can help aid in a difficult delivery and keep intervention to a minimum, right? It seems like such an easy option to spare mom and baby from stressful situations that require longer recovery periods, bonding/breastfeeding interruption, etc. Makes me very sad/mad.
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#18 of 47 Old 04-22-2009, 07:12 PM
 
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I was in a similar position as your patient and i told them (OB and midwife) what i wanted, wrote a birth plan, etc. basically they smiled and nodded and then told me i had to have a section the week before me EDD. if the doctor isnt obviously supportive she should find a new one. you can only do so much and if alt. birthing positions aren't aa patients right then there isnt much you can do yk?
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#19 of 47 Old 04-22-2009, 07:14 PM
 
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Why is this? They DO know that different positions can help aid in a difficult delivery and keep intervention to a minimum, right? It seems like such an easy option to spare mom and baby from stressful situations that require longer recovery periods, bonding/breastfeeding interruption, etc. Makes me very sad/mad.
Yes... but who is trying to avoid intervention? Intervention makes the big bucks. Why get mom into a more comfortable position when you can use modern medicine instead?
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#20 of 47 Old 04-22-2009, 07:36 PM - Thread Starter
 
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Yes... but who is trying to avoid intervention? Intervention makes the big bucks. Why get mom into a more comfortable position when you can use modern medicine instead?

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#21 of 47 Old 04-22-2009, 08:41 PM
 
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A little true story: my eldest son recently spent an overnight camping with a small group of men who wanted him to teach them about survival. One of the attendees just happened to be an OB whom I know (my son didn't know this until he later told me the story). The OBs nickname on the ward is 'Caesarian Sackley' (fake last name given here, of course). They got to talking about his work, and he mentioned that while he does do OB work, his favorite is the Gyn part--cuz he does lots of surgeries, hysterectomies and so forth. My son says something like "Oh, I guess that's kind of a mixed thing, eh? Like, great that you can help solve a woman's problem, too bad she has to lose her uterus in the process" The OB looked at him kinda baffled, then said something like "You know, most of us go into OB for the surgery in the first place. THat's the part we really want to do most." My son tells me (my homeborn son among 5 homeborn sibs and one transfer, son of a hb mw) that he quickly changed the subject since he didn't want to be rude to his client....

But yeah. I think this is a pretty fair observation from that doc. OBs wouldn't become OBs if what they wanted was to be hb mws. Or any kind of mw, they like to DO things to women.
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#22 of 47 Old 04-22-2009, 09:45 PM
 
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#23 of 47 Old 04-23-2009, 01:07 AM
 
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Unfortunately most hospitals do make you sign a paper as part of your registration process that gives them (and their Dr's) full permission to do as the please and gives them the right to make medical decisions without having to ask consent in the moment. It is a standard intake form and I'm sure most moms sign it without even noticing. And most hospital make you sign it if you plan on delivering at their hospital.
Actually there is a law that says (in the US) a laboring woman cannot be turned away. I am blanking here, someone please post the name if you know what I mean for clarity, it's often referred to be an acronym or initials like the LWACA? Mommy brain, I could be totally off.. But, basically, it means they have to admit you regardless of whether you sign that form- one should probably know the name of the law if she is going to assert this right though lol. In any other case they can deny admission, but in a case of being in labor, or a few other specified circumstances, they cannot do this the usual way.

I actually didn't sign it upon admission because they were really busy and so I was pretty much ignored in triage for an hour as they were more than full, and then when I got to my room I was practically pushing so there was really no time. I signed it post-birth. And at that time, I made my own additions and subtractions Now I did have very supportive midwives, so I wasn't too worried, but in a hospital setting, better safe than sorry with such things.. If one doesn't want to do this in active labor, however, I'd advise her to get the form in advance, make her changes, and then put it in your or her birth folder to have and sign when she arrives.

Now of course the bigger issues here are that the client is expecting you to overstep your role and that her care provider is not on board with her wishes, and these should be addressed. But I also think this is worth educating a client about in certain circumstances- for example, if they are saying she absolutely has to consent to something (certain position for pushing, c-section for breech, etc.) that she both does not have to consent, and does not have to sign any blanket statement consent forms to be "allowed" admission whilst in labor. But I also totally agree that having a care provider who is on board is much preferred and prevents many potential problems. That said, if for some reason this is not an option (small town with only one option for care, insurance/finances, etc.) or if she does choose to stay with this provider, I would educate her on that (pushing issue aside, I don't think it is wise for any woman desiring a natural birth in a hospital setting to sign her life away like that, and like you said, most women don't even think about it as you are obviously distracted and it's just presented as a formality or procedural necessity without understanding what rights are given up) and also make clear that you can remind her of her wishes, but she has to be willing and able to advocate for herself in any such issue.

By the way, I don't think I have posted on this forum but I am working on my doula certification and looking into options to pursue midwifery, so I hope to talk more with you mamas

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#24 of 47 Old 04-23-2009, 01:19 AM - Thread Starter
 
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The OB looked at him kinda baffled, then said something like "You know, most of us go into OB for the surgery in the first place. THat's the part we really want to do most."
Yes, I believe it. I became deathly ill with kidney stones and infections when my oldest was 5 months old. After 4 surgeries in 3 days, my mother, addressing the Urologist, apologized, in a way, for my emergency calling him into the OR in the middle of the night for the second time. He just smiled at her, and said 'I love what I do. I get excited at the opportunity to be in the OR no matter the time.'

Huh.

Makes sense. I've watched enough Grey's anatomy to know the dangers of doctors having any kind of emotional attachment to their patients, which is most likely the reason for the seeming lack of concern for the Mom and babe and any medical/physical/emotional problems that occur as a result of interventions and C-sections. That, along with a love for surgery makes a DR a great resource for emergencies...which birth is not.
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#25 of 47 Old 04-23-2009, 02:09 AM
 
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Actually there is a law that says (in the US) a laboring woman cannot be turned away. I am blanking here, someone please post the name if you know what I mean for clarity, it's often referred to be an acronym or initials like the LWACA? Mommy brain, I could be totally off.. But, basically, it means they have to admit you regardless of whether you sign that form- one should probably know the name of the law if she is going to assert this right though lol. In any other case they can deny admission, but in a case of being in labor, or a few other specified circumstances, they cannot do this the usual way.


The abbreviation is EMTALA (m-tah-lah) - can't remember off hand what the letters stand for but it can be googled.

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#26 of 47 Old 04-23-2009, 11:05 AM
 
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Why is this? They DO know that different positions can help aid in a difficult delivery and keep intervention to a minimum, right?
i think it's because it's how they're trained, they feel comfortable that way (pop the bed up to their height, pull down the light and all they have to do is move their hands more or less) and they really don't know anything else. AND the majority of their patients do not ask for anything different.

i don't know if they actually believe different positions are helpful, at least not many of them.

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#27 of 47 Old 04-23-2009, 11:20 AM
 
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i think it's because it's how they're trained, they feel comfortable that way (pop the bed up to their height, pull down the light and all they have to do is move their hands more or less) and they really don't know anything else. AND the majority of their patients do not ask for anything different.

i don't know if they actually believe different positions are helpful, at least not many of them.
I wonder if they have seen so many births in only the one position that in their head they really don't believe other positions are beneficial anymore. They have seen plenty of babies come out just fine in this one position over and over and over again, so it becomes ingrained that this works..... even if something else may work better.

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#28 of 47 Old 04-23-2009, 12:22 PM
 
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Unfortunately most hospitals do make you sign a paper as part of your registration process that gives them (and their Dr's) full permission to do as the please and gives them the right to make medical decisions without having to ask consent in the moment. It is a standard intake form and I'm sure most moms sign it without even noticing. And most hospital make you sign it if you plan on delivering at their hospital.
In Canada, and I'm pretty sure it's the same in the States, verbal permission/refusal at the time overrides anything signed previously. You sign a general consent ahead of time but you can verbally refuse any treatment and that has legal force.

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#29 of 47 Old 04-24-2009, 12:20 AM
 
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I am coming late to this thread, but several things stick out--one, the client needs to make peace with the lithotomy position or find a new caregiver. It's not in the doula's scope of practice to change how a practitioner practices.

Also, the doula in this situation ought to take a close look at the dynamics of her relationship with her client. I'm seeing red flags with regard to the client taking responsibility for her birth, and I've learned the hard way who catches the blame (from the client's pov) when the client expects the doula to be her savior and still winds up with a birth experience she didn't want or expect.

The last thing--my clients have often asked me which option to choose when a baby needs assistance in getting out, forcepts or vacuum extraction. My answer is always the same: whichever tool your doctor is most comfortable and experienced with. No one wants their doctor to be clumsy or ineffective--or worse.

I see catching at a normal vaginal delivery in much the same way. If the careprovider insists on lithotomy, maybe that is best.

Ideally, a broader education on the part of the cp would be the first choice, but in the real world, if the cp doesn't know how to slow down a delivery or support a perineum during a squat or h/k, sometimes those babies come flying out, and if mom isn't free to use her instincts/hands to slow it down, a very bad tear can occur.

Just my .02

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#30 of 47 Old 04-24-2009, 02:18 PM
 
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The abbreviation is EMTALA (m-tah-lah) - can't remember off hand what the letters stand for but it can be googled.
EMTALA = Emergency Medical Treatment and Active Labor Act Note-This does not necessarily apply to every hospital!! It is an "anti-dumping" law that prevents hospitals from refusing care or transferring patients who have no insurance or poorly paying insurance like Medicade, to another hospital, like a charity hospital or county hospital. It's also supposed to be anti-discriminatory, so that poor patients aren't treated less well than patients with good insurance.


What does that mean?
-from EMTALA Dot Com

1. What is EMTALA?

The Emergency Medical Treatment and Active Labor Act is a statute which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable medical condition.

EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as "the COBRA law". In fact, a number of different laws come under that general name. Another very familiar provision, also referred to under the COBRA name, is the statute governing continuation of medical insurance benefits after termination of employment.


Reportedly, a 1989 amendment to the statute removed the word "active" from the official name of the statute. The amendment, however, cannot be found in the report of the official public law.
EMTALA is also known as Section 1867(a) of the Social Security Act. It is included as part of the section of the U.S. Code which governs Medicare.

EMTALA applies only to "participating hospitals" -- i.e., to hospitals which have entered into "provider agreements" under which they will accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program for services provided to beneficiaries of that program. In practical terms, this means that it applies to virtually all hospitals in the U.S., with the exception of the Shriners' Hospital for Crippled Children and many military hospitals. Its provisions apply to all patients, and not just to Medicare patients. (See Section 15 below.)

The avowed purpose of the statute is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to "charity hospitals" or "county hospitals" because they are unable to pay or are covered under the Medicare or Medicaid programs. This purpose, however, does not limit the coverage of its provisions -- see Sections 15 and 16 below.

EMTALA is primarily but not exclusively a non-discrimination statute. One would cover most of its purpose and effect by characterizing it as providing that no patient who presents with an emergency medical condition and who is unable to pay may be treated differently than patients who are covered by health insurance. That is not the entire scope of EMTALA, however; it imposes affirmative obligations which go beyond non-discrimination. See Section 16 below.

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