In section. While these procedures are appropriate
In the article titled, Disrespect and Abuse in Childbirth and Respectful Maternity Care, the White Ribbon Alliance examines the complications associated with over-medicalization. Over-medicalization refers to the excessive or inappropriate use of interventions (White Ribbon Alliance, n.d.
). In the context of childbirth, this can include interventions related to induction and augmentation, such as the use of Pitocin, continuous electronic fetal monitoring (EFM), epidural, and Cesarean section. While these procedures are appropriate at times, when overused, they can contribute to morbidity and mortality (Miller, et al., 2016). During my clinical experience at MedStar Franklin Square Medical Center, I observed an excessive use of interventions, and based on conversations with the staff, assumed its implementation to be standard practice. While reflecting upon my experience in Labor and Delivery (L&D) at Franklin Square, it’s only fair to explore my own identity and how it has influenced how I view care.
I was raised by my grandmother whose views on the medical system were far from conventional. Having birthed three out of her four children at home, she saw no need to outsource our family’s medical needs. As a child, natural remedies were the first line of defense. It was her commitment to complimentary medicine that influenced my view on healthcare and led me to the readings of Ina May Gaskin, a fellow natural birth advocate, who fell in line with my grandmothers teachings. It was Gaskin’s work that inspired my interest in midwifery and led me to nursing school.
As such, I prefer to approach all care with the ideals of inflicting the least amount of harm possible, while still effectively achieving the necessary outcome – an ethical foundation referred to as nonmaleficence. This bias is worth noting, as it may help to explain why I perceived some of the behavior I observed in L;D to be an example of over-medicalization. There is one particular experience that highlights the over-medicalization in healthcare and how a straightforward induction can escalate to a major surgery. I was assigned to a nurse whose patient was preeclamptic with a planned induction. First, the patient was dilated using a foley bulb, put on continuous electronic fetal monitoring, and started on Pitocin. Later, she progressed to an amniotomy, a fetal scalp electrode, and an epidural. Finally, she was headed to a cesarean section (c-section).
It was this sequence of interventions, one bleeding into the next, that caught my attention. Early in the series of interventions there was an unlikely fetal monitoring strip containing minimal variability accompanied by late decelerations. The nurse could have decreased the Pitocin to ease the fetal distress, but preferred to maintain it. When I questioned the preceptor about the nurses actions her response was that some nurses are “aggressive with their Pitocin.” At this point, the doctor arrived to discuss a possible c-section.
Once again, I questioned the nurse about how quickly they had decided on a c-section and her response was “…some doctors are itching to go to the OR, and this doctor is one of them.” The take-away is that some nurses will aggressively give their patient Pitocin, even in the sight of fetal distress, and some doctors prefer c-section. Where in this conversation are we considering the needs of the patient? Additional conversations with staff have led me to believe that less invasive birthing methods are ignored in lieu of over-medicalization. Curious about the rates of natural birthing in the hospital setting, I’ve asked nurses on duty how often they took part in or observed a natural birth. Their response was that while it happened on occasion, it was not their preference and was not the norm. Their consensual lack of enthusiasm for the natural birthing process seemed to be driven by the extra amount of time and care that it required.
In my minimal experience on the labor and delivery floor, it seemed that provider identities were most strongly driven by their time and resources limitations. I witnessed these identities often lead to interventions that were in the interest of convenience and predictability for the provider, at the expense of the patient. Considering implicit bias and racism, it is worth noting that the patient I attended was an African American woman. I am uncertain to the degree that her care was influenced by race. However, my instinct is that the care provided was not racially driven, but rather, seemed to be standard practice amongst the current care staff. Practically speaking, there are a number of approaches nurses can take to combat the level of intervention in care. The first step is proper education and awareness building.
It is essential that L&D nurses possess an adequate education on non-pharmacological techniques to encourage labor progress, including changing positions, ambulating, and use of objects, such as a birthing ball. Equally important is an education on why these techniques may be preferable to their more invasive counterparts. Equally important is the inclusion of education on interventions and the risks that may accompany.