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The New Birth Experience
facts and opinion The New Birth Experience R. CLA Y BURCHELL, MD, FA COG and JANE GLJNN,RN, MS Recently emerging consumer demands and expectations concerning labor and delivery are put into perspective vis-a-vis professional unpreparedness and resistance.
Obstetrics is undergoing profound change and all involved in the care of pregnant women are challenged to cope with many problems. One of the most perplexing is the pressure to modify clinical practice so that an obstetric patient can have the individual birth experience she desires. Both nurse and obstetrician are involved in the eye of this storm. Together, as professionals, they have worked for years in complementary roles to provide care and reduce
fetal, and perhaps less on maternal, safety. In the last two decades, pregnancy has become relatively safe for both mother and fetus. Now, after this struggle to improve the quality of obstetric care, there seems to be a movement to turn back the clock and focus less on safety and more on patient desire. This is a new experience for physicians and nurses. Many are baffled by the meaning of, and emotional force behind, the requests. It seems
Either nurse or physician may inadvertently be in conflict with a patient; the result is always more difficult medical care. mortality. Additionally, the nurse has created the environment for the patient whether in an office or a delivery suite. Either nurse or physician may inadvertently be in conflict with a patient; the result is always more difficult medical care. T h e trend toward a n individualized birth experience would have been unbelievable half a century ago. At that time, virtually every young woman about to become a mother personally knew, or knew of, someone who had died in childbirth. She was realistically concerned about her own safety and, in a sense, had to consider a healthy baby an extra dividend. Maternal survival was also paramount from the obstetric viewpoint and even living fetuses were sacrificed in some instances for the mother’s safety. During the ensuing years, childbirth became increasingly safe so that it was realistic to focus more on
250
incomprehensible t h a t patients would actually be demanding that less emphasis be placed on safety. Often what the patient wants threatens to result in medical care that has less margin of safe9 and might therefore be considered inferior or even dangerous. Immediately professional and patient are placed in an adversary position and both react negatively. Both sense that something is wrong and that they should be working cooperatively together. Often neither understands the feelings of the other and has no idea of how to communicate effectively. Frequently, the misunderstanding is solved when they decide to separate and the patient seeks another hospital or obstetrician more sympathetic to her wishes. Both are injured by the process even though, individually, each may feel righteous a n d t h a t there was no other alternative.
Recently several things have happened that make this a serious problem and one that deserves specific attention with a concerted attempt at solution. First, there appears to be a n increasing number of patients who are requesting that obstetricians and hospitals modify obstetric care. These requests are a daily occurence in some parts of the country. Second, there is evidence that some of the modifications patients have been requesting have some scientific basis and that strong consideration should be given to granting them on the basis of improved care. The evidence is not conclusive but nothing erodes a professional position as much as having the patient proved right and the doctor or nurse proved wrong at the end of a medical conflict. T h e third factor is that larger numbers of patients are presenting their views in groups as members of formal organizations. There is danger that misunderstandings on a one-to-one basis may begin to be viewed as a generalized conflict between all obstetricians/nurses and their patients. The possible tragic consequence could be that society would view obstetricians and obstetric nurses as natural adversaries to pregnant women, with the result that patients would seek other advocates to fill the traditional roles of the physician and nurse. In other words, there seems to be evidence that what began as isolated doctorpatient misunderstanding could evolve into a broad trend involving whole groups of individuals in conflict. Ironically from a behavioralcounseling point of view this type of misunderstanding and resulting conJuly/August 1980JOCN Nursing 0090-031 1 /80/07 I 7-0250f0 100
flict has a rather straightforward approach to solution, with an excellent prognosis. T h e fact that patients and physician or nurse are not in initial agreement certainly need not result in termination of the relationship zf the professional understands the source of conflict and knows how to take a leadership role in enabling
her fear. If her requests are discussed in terms of loss of control, fear will be allayed. Physicians and nurses can easily understand how patients feel in this respect because hospitalized professionals are among the patient groups most reluctant to be traditionally dependent. More often in obstetrics today the
There is danger that misunderstandings on a one-to-one basis may begin to be viewed as a generalized conflict between all obstetricians/nurses and their patients. both of them to find a solution. The responsibility for initiative in solution should rest with the professional because he or she is repetitively faced with the problem and is already in a helping role by nature of the relationship. The theoretical solution to a problem such as this involves discussion to the point that both individuals understand their own a n d each other’s feelings. After understanding the individual viewpoints, they can determine areas of agreement and disagreement. Frequently, for example, there is agreement on goals and disagreement upon some aspects of implementation. The aspects of disagreement may be manageable, and at any rate, the process of understanding and defining areas of agreement has moved the two individuals away from an adversary position. Usually a solution is possible, and the greatest obstacle in the past has been that physicians and nurses may not have had sufficient experience in conflict resolution to initiate an effective attempt. For a practical solution, the first goal of the professional is to understand the patient. Often the list of requests to have care modified is secondary to some other feelings that may not be totally conscious to her. In other words, she has a strong urge to take an active part in her own care, but may not be sure just why. Sometimes there is a fear about losing control. Patients feel less helpless if they can take part in decision making. Patients in this category are usually quickly aware of their feelings if the specific point is raised in discussion. Determining this is important because if the requests are directly negated it will only increase July/August 1980JOCN Nursing
requests for care modification arise from high expectzitions and a search for a “perfect birth experience”. Two patient experiences are illustrative. One patient, a nurse, had had a third child about six months previously. She was both overjoyed and sad about the experience. She was overjoyed because her husband had been with her throughout labor, birth, recovery, and the rooming-in experience in the hospital. She wistfully said it had been a perfect experience except for the enema. She was sorry and angry with herself that she had not refused to have an enema. Several things were apparent from what she said. Everything had gone perfectly in terms of results. She had achieved all of the things she desired. Yet her expectations were so high that the fact that she had not refused an enema had spoiled to some extent this event in her life. The other story was similar. This patient, a nurse and doctor’s wife, had also had a perfect experience in terms of results. Her experience had been marred, however, because she and her husband had to argue with staff to have him remain with her when she was admitted. They felt that the experience would have been perfect if there had been no need for any conflict to arise. These experiences are important because they demonstrate the in-
From a behavioral point of view this was a prerequisite for considering the beauty and joy of the birth experience. In other words, like it or not, increasing numbers of patients are approaching birth with expectations of joy and beauty in addition to excellent results. This concept of a “perfect medical experience” is completely foreign to many nurses and physicians. They would just be grateful if the results could always be good. Sometimes it seems as if the patient cares little about the accomplishments of the last fifty years since these are so often taken for granted. H e r expectations often seem entirely unrealistic, and to make matters most confusing, some of the demands she says will make the experience more beautiful, actually may reduce the margin of safety. For perspective, it is important to understand several things. First, the accomplishments a r e not being downgraded but actually are a prerequisite for a consideration of birth a s a joyous experience. When women worried a b o u t dying in childbirth, they were happy if the baby even survived. When they no longer had to worry about themselves, they focused on the baby. Now they feel good results are the norm so they can focus on birth as a “peak experience”. Understanding what the patient is trying to accomplish enables the obstetrician, and obstetric nurse, to explain the medical problems and cooperate with the patient to insure that both goals can be achieved. Fundamentally the goals of everyone involved are not conflicting and, on close scrutiny, are to a great extent compatible. There is another aspect of this trend that is confusing and often misunderstood. Medicine and nursing are helping professions and with few exceptions our birthrights have
The greatest obstacle in the past has been that physicians and nurses may not have had sufficient experience in conflict resolution to initiate an effective attempt. tensity of focus on birth as a sz,gnz$cant lzjie event rather than a medical occiirrence. It was also evident that these patients considered good medical results as a matter of course.
involved caring, helping, laying on of hands, and relieving pain. This approach is our heritage, the one we learned and obviousfy the on? we practice
25 1
The exceptions to this rule occur in psychiatry, in other types of counseling, and in some areas like caring for the dying patient when we are unable to help in a traditional sense. These are areas that the helping professional often finds difficult. They are difficult because they require a different perspective and approach. Instead of helping directly we must help the patient indirectly to help herself: Slightly different words but profoundly different implementation! The contrast can be illustrated by comparing the difference between buying someone fish for dinner at the market and teaching him how to fish so he can catch his own dinner. No fisherman would have a moment’s difficulty in comprehending the vast difference between the two approaches. In addition to seeking joy and b e a u t y in b i r t h , some of these women are using the experience to measure their own potential. This also needs to be understood because
point would be to compare two runners a l o n g a r o a d who a r e exhausted. One who was running from something dangerous would profoundly appreciate being picked up in a car or directly assisted. Another who was approaching the finish line of a marathon would be tragically eliminated if we helped in the same way. The pregnant woman who is utilizing birth as a life event to reach her potential, is like the marathon runner; she does not need direct help but does need certain kinds of indirect protection. Sometimes she needs to be encouraged to keep going, and sometimes she needs to be removed from a race that is becoming dangerous. The concept of using a medical experience for self-fulfillment has some obvious problems. A patient who is unable to succeed according to her expectations may feel she has failed and become depressed. It is important for everyone to assist her in adopting realistic expectations.
Although the nurse or physician is a coach in a sense and needs to encourage and support the patient in reaching as far as she desires, there may come a time when she needs direct help for medical reasons. sometimes we interfere with the process by directly helping rather than assisting or enabling the patient to reach as far as she can. This means that the obstetric nurse and obstetrician may need to avoid direct helping, and this will run counter to their natural instincts and training. Patients have been upset that medication was not withheld a little longer even though they complained of pain. Most of us are experienced in helping patients go through prepared childbirth, but we may not always have understood why they might ask for medication during late labor a n d then subsequently be sorry it was given. The best analogy to illustrate this
252
There is added responsibility in another area. Although the nurse or physician is a coach in a sense and needs to encourage and support the patient in reaching as far as she desires, there may come a time when she needs direct help for medical reasons. Again by analogy, there are times when marathon races must be t e r m i n a t e d by t h e coach even though the runner is disappointed. Patients should not suffer medically in trying to achieve a desired nonmedical goal. Prospective discussion of these two problem areas before delivery usually goes a long way in promoting understanding and preventing subsequent resentment. This approach to the obstetric pa-
tient who wants to be an active partner in her care will not solve all the problems. All obstetricians, obstetric nurses, and hospitals will not be interested in or sympathetic to this type of practice. There will be times when patients make demands that cannot be granted in good conscience. When there is irreconcilable difference in viewpoint, the patient should find other obstetric care. However, it is a shame when the patient feels she must seek alternative care because of a misunderstanding that could have been cleared up. Separation, if necessary, should be made on the basis of a rational decision, not misunderstanding. Obstetrics is the one and only area of medical and nursing care that patients look forward to as an event of joy and beauty. We have done well enough medically in the last halfcentpry so that this is possible. Too often, due to misunderstanding, the patient says “I want a joyous birth” and we, in essence, say you need a safe birth and let’s forget about the joy. If the patients are wrong and there is no beauty in birth, should we actually be the ones to shatter their dreams? If on the other hand the patients are right a n d birth should be joyous, resistance will deny our birthright and we will be “driven from the temple”.
Address for correspondence: R. Clay Burchell, MD, FACOG, Director, Department of Obstetrics and Gynecology, Hartford Hospital, 80 Seymour Street, Hartford, C T 061 15. Clay Burchell is director of the Department of Obstetrics and Gynecology at Hartford Hospital, Hartford, Connecticut, and a member of the Scientijic Program Committee for the Annual Clinical Meeting of ACOG. Jane Gunn is clinical coordinator of Obstetrical and Gynecological Nursing at Hartford Hospital and a member of the JOGN Editorial Board. Both are previous article contributors to the Journal.
July/August 1980JOCN Nursing
Obstetrics is undergoing profound change and all involved in the care of pregnant women are challenged to cope with many problems. One of the most perplexing is the pressure to modify clinical practice so that an obstetric patient can have the individual birth experience she desires. Both nurse and obstetrician are involved in the eye of this storm. Together, as professionals, they have worked for years in complementary roles to provide care and reduce
fetal, and perhaps less on maternal, safety. In the last two decades, pregnancy has become relatively safe for both mother and fetus. Now, after this struggle to improve the quality of obstetric care, there seems to be a movement to turn back the clock and focus less on safety and more on patient desire. This is a new experience for physicians and nurses. Many are baffled by the meaning of, and emotional force behind, the requests. It seems
Either nurse or physician may inadvertently be in conflict with a patient; the result is always more difficult medical care. mortality. Additionally, the nurse has created the environment for the patient whether in an office or a delivery suite. Either nurse or physician may inadvertently be in conflict with a patient; the result is always more difficult medical care. T h e trend toward a n individualized birth experience would have been unbelievable half a century ago. At that time, virtually every young woman about to become a mother personally knew, or knew of, someone who had died in childbirth. She was realistically concerned about her own safety and, in a sense, had to consider a healthy baby an extra dividend. Maternal survival was also paramount from the obstetric viewpoint and even living fetuses were sacrificed in some instances for the mother’s safety. During the ensuing years, childbirth became increasingly safe so that it was realistic to focus more on
250
incomprehensible t h a t patients would actually be demanding that less emphasis be placed on safety. Often what the patient wants threatens to result in medical care that has less margin of safe9 and might therefore be considered inferior or even dangerous. Immediately professional and patient are placed in an adversary position and both react negatively. Both sense that something is wrong and that they should be working cooperatively together. Often neither understands the feelings of the other and has no idea of how to communicate effectively. Frequently, the misunderstanding is solved when they decide to separate and the patient seeks another hospital or obstetrician more sympathetic to her wishes. Both are injured by the process even though, individually, each may feel righteous a n d t h a t there was no other alternative.
Recently several things have happened that make this a serious problem and one that deserves specific attention with a concerted attempt at solution. First, there appears to be a n increasing number of patients who are requesting that obstetricians and hospitals modify obstetric care. These requests are a daily occurence in some parts of the country. Second, there is evidence that some of the modifications patients have been requesting have some scientific basis and that strong consideration should be given to granting them on the basis of improved care. The evidence is not conclusive but nothing erodes a professional position as much as having the patient proved right and the doctor or nurse proved wrong at the end of a medical conflict. T h e third factor is that larger numbers of patients are presenting their views in groups as members of formal organizations. There is danger that misunderstandings on a one-to-one basis may begin to be viewed as a generalized conflict between all obstetricians/nurses and their patients. The possible tragic consequence could be that society would view obstetricians and obstetric nurses as natural adversaries to pregnant women, with the result that patients would seek other advocates to fill the traditional roles of the physician and nurse. In other words, there seems to be evidence that what began as isolated doctorpatient misunderstanding could evolve into a broad trend involving whole groups of individuals in conflict. Ironically from a behavioralcounseling point of view this type of misunderstanding and resulting conJuly/August 1980JOCN Nursing 0090-031 1 /80/07 I 7-0250f0 100
flict has a rather straightforward approach to solution, with an excellent prognosis. T h e fact that patients and physician or nurse are not in initial agreement certainly need not result in termination of the relationship zf the professional understands the source of conflict and knows how to take a leadership role in enabling
her fear. If her requests are discussed in terms of loss of control, fear will be allayed. Physicians and nurses can easily understand how patients feel in this respect because hospitalized professionals are among the patient groups most reluctant to be traditionally dependent. More often in obstetrics today the
There is danger that misunderstandings on a one-to-one basis may begin to be viewed as a generalized conflict between all obstetricians/nurses and their patients. both of them to find a solution. The responsibility for initiative in solution should rest with the professional because he or she is repetitively faced with the problem and is already in a helping role by nature of the relationship. The theoretical solution to a problem such as this involves discussion to the point that both individuals understand their own a n d each other’s feelings. After understanding the individual viewpoints, they can determine areas of agreement and disagreement. Frequently, for example, there is agreement on goals and disagreement upon some aspects of implementation. The aspects of disagreement may be manageable, and at any rate, the process of understanding and defining areas of agreement has moved the two individuals away from an adversary position. Usually a solution is possible, and the greatest obstacle in the past has been that physicians and nurses may not have had sufficient experience in conflict resolution to initiate an effective attempt. For a practical solution, the first goal of the professional is to understand the patient. Often the list of requests to have care modified is secondary to some other feelings that may not be totally conscious to her. In other words, she has a strong urge to take an active part in her own care, but may not be sure just why. Sometimes there is a fear about losing control. Patients feel less helpless if they can take part in decision making. Patients in this category are usually quickly aware of their feelings if the specific point is raised in discussion. Determining this is important because if the requests are directly negated it will only increase July/August 1980JOCN Nursing
requests for care modification arise from high expectzitions and a search for a “perfect birth experience”. Two patient experiences are illustrative. One patient, a nurse, had had a third child about six months previously. She was both overjoyed and sad about the experience. She was overjoyed because her husband had been with her throughout labor, birth, recovery, and the rooming-in experience in the hospital. She wistfully said it had been a perfect experience except for the enema. She was sorry and angry with herself that she had not refused to have an enema. Several things were apparent from what she said. Everything had gone perfectly in terms of results. She had achieved all of the things she desired. Yet her expectations were so high that the fact that she had not refused an enema had spoiled to some extent this event in her life. The other story was similar. This patient, a nurse and doctor’s wife, had also had a perfect experience in terms of results. Her experience had been marred, however, because she and her husband had to argue with staff to have him remain with her when she was admitted. They felt that the experience would have been perfect if there had been no need for any conflict to arise. These experiences are important because they demonstrate the in-
From a behavioral point of view this was a prerequisite for considering the beauty and joy of the birth experience. In other words, like it or not, increasing numbers of patients are approaching birth with expectations of joy and beauty in addition to excellent results. This concept of a “perfect medical experience” is completely foreign to many nurses and physicians. They would just be grateful if the results could always be good. Sometimes it seems as if the patient cares little about the accomplishments of the last fifty years since these are so often taken for granted. H e r expectations often seem entirely unrealistic, and to make matters most confusing, some of the demands she says will make the experience more beautiful, actually may reduce the margin of safety. For perspective, it is important to understand several things. First, the accomplishments a r e not being downgraded but actually are a prerequisite for a consideration of birth a s a joyous experience. When women worried a b o u t dying in childbirth, they were happy if the baby even survived. When they no longer had to worry about themselves, they focused on the baby. Now they feel good results are the norm so they can focus on birth as a “peak experience”. Understanding what the patient is trying to accomplish enables the obstetrician, and obstetric nurse, to explain the medical problems and cooperate with the patient to insure that both goals can be achieved. Fundamentally the goals of everyone involved are not conflicting and, on close scrutiny, are to a great extent compatible. There is another aspect of this trend that is confusing and often misunderstood. Medicine and nursing are helping professions and with few exceptions our birthrights have
The greatest obstacle in the past has been that physicians and nurses may not have had sufficient experience in conflict resolution to initiate an effective attempt. tensity of focus on birth as a sz,gnz$cant lzjie event rather than a medical occiirrence. It was also evident that these patients considered good medical results as a matter of course.
involved caring, helping, laying on of hands, and relieving pain. This approach is our heritage, the one we learned and obviousfy the on? we practice
25 1
The exceptions to this rule occur in psychiatry, in other types of counseling, and in some areas like caring for the dying patient when we are unable to help in a traditional sense. These are areas that the helping professional often finds difficult. They are difficult because they require a different perspective and approach. Instead of helping directly we must help the patient indirectly to help herself: Slightly different words but profoundly different implementation! The contrast can be illustrated by comparing the difference between buying someone fish for dinner at the market and teaching him how to fish so he can catch his own dinner. No fisherman would have a moment’s difficulty in comprehending the vast difference between the two approaches. In addition to seeking joy and b e a u t y in b i r t h , some of these women are using the experience to measure their own potential. This also needs to be understood because
point would be to compare two runners a l o n g a r o a d who a r e exhausted. One who was running from something dangerous would profoundly appreciate being picked up in a car or directly assisted. Another who was approaching the finish line of a marathon would be tragically eliminated if we helped in the same way. The pregnant woman who is utilizing birth as a life event to reach her potential, is like the marathon runner; she does not need direct help but does need certain kinds of indirect protection. Sometimes she needs to be encouraged to keep going, and sometimes she needs to be removed from a race that is becoming dangerous. The concept of using a medical experience for self-fulfillment has some obvious problems. A patient who is unable to succeed according to her expectations may feel she has failed and become depressed. It is important for everyone to assist her in adopting realistic expectations.
Although the nurse or physician is a coach in a sense and needs to encourage and support the patient in reaching as far as she desires, there may come a time when she needs direct help for medical reasons. sometimes we interfere with the process by directly helping rather than assisting or enabling the patient to reach as far as she can. This means that the obstetric nurse and obstetrician may need to avoid direct helping, and this will run counter to their natural instincts and training. Patients have been upset that medication was not withheld a little longer even though they complained of pain. Most of us are experienced in helping patients go through prepared childbirth, but we may not always have understood why they might ask for medication during late labor a n d then subsequently be sorry it was given. The best analogy to illustrate this
252
There is added responsibility in another area. Although the nurse or physician is a coach in a sense and needs to encourage and support the patient in reaching as far as she desires, there may come a time when she needs direct help for medical reasons. Again by analogy, there are times when marathon races must be t e r m i n a t e d by t h e coach even though the runner is disappointed. Patients should not suffer medically in trying to achieve a desired nonmedical goal. Prospective discussion of these two problem areas before delivery usually goes a long way in promoting understanding and preventing subsequent resentment. This approach to the obstetric pa-
tient who wants to be an active partner in her care will not solve all the problems. All obstetricians, obstetric nurses, and hospitals will not be interested in or sympathetic to this type of practice. There will be times when patients make demands that cannot be granted in good conscience. When there is irreconcilable difference in viewpoint, the patient should find other obstetric care. However, it is a shame when the patient feels she must seek alternative care because of a misunderstanding that could have been cleared up. Separation, if necessary, should be made on the basis of a rational decision, not misunderstanding. Obstetrics is the one and only area of medical and nursing care that patients look forward to as an event of joy and beauty. We have done well enough medically in the last halfcentpry so that this is possible. Too often, due to misunderstanding, the patient says “I want a joyous birth” and we, in essence, say you need a safe birth and let’s forget about the joy. If the patients are wrong and there is no beauty in birth, should we actually be the ones to shatter their dreams? If on the other hand the patients are right a n d birth should be joyous, resistance will deny our birthright and we will be “driven from the temple”.
Address for correspondence: R. Clay Burchell, MD, FACOG, Director, Department of Obstetrics and Gynecology, Hartford Hospital, 80 Seymour Street, Hartford, C T 061 15. Clay Burchell is director of the Department of Obstetrics and Gynecology at Hartford Hospital, Hartford, Connecticut, and a member of the Scientijic Program Committee for the Annual Clinical Meeting of ACOG. Jane Gunn is clinical coordinator of Obstetrical and Gynecological Nursing at Hartford Hospital and a member of the JOGN Editorial Board. Both are previous article contributors to the Journal.
July/August 1980JOCN Nursing