Building a Birth Team Based on Trust

When you build trust and open communication, in most cases you’ll find that you will create a team that keeps you solidly at the center of the experience and where you are all working together towards your shared goals.

When I supported a couple who was on hospital bedrest for weeks, they needed a little extra doula care. We were on the phone a lot, messaging back and forth, I went to see her as often as I could.

It seemed every week there was a new reason to worry, an additional test, another 24 hours of observation. Often, I would remind her that she was an autonomous human being and not a nameless condition. And knowing that I couldn’t be available every time the doctors came in to recommend a course of action, we also talked about what she needed to know in order to weigh the doctor’s opinions against her own instincts.

One morning, she called to ask me about a genetic test that her doctor was advising based on something they noticed in the last fetal monitor. She was being monitored twice a day routinely at this point.

“Remember,” I said, “Being in the hospital, you’re under observation – every change, fluctuation, and blip in your and your babies’ condition is going to be noticed and recorded. And because of that we don’t know what’s your normal, and what would innocuously go unnoticed if you were at home.”
“Right” her voice was much calmer now. “So how do I know if I need to do the tests they’re suggesting?”

“First of all, know where they are coming from. When you know someone’s motivations, you hold more information about how to process their recommendation.

The job of the hospital staff and your nurses and doctors in particular, are to keep you and your babies safe. They can’t ignore something that they observe, even if it’s not likely to be serious. Even if it’s statistically a very low risk. Because if it turns out to be serious, if it becomes worse, if you are in that small percentage of people that this issue turns into a complication – that’s on them.

But YOU have the power of your intuition. You aren’t held liable for the protocols. You can ask questions to determine if the doctor’s suggestion or recommendation is based on evidence, and an actual risk, or if this is more of “let’s play it safe and check this out, or take this course of action.”

Either way, once you have that information, you still have a choice to make. Take the recommended course, or not. Or ask about an alternative.

Just because the doctor’s motivation is “play it safe” that doesn’t mean that you should do what they recommend. But it does mean you now know how to ask the next question. And it means that if you do decide to go ahead, you are more aware of the risks, the reason you’re doing it and what to do with the results.

This allows fear to take a back seat.

It also has another benefit.
When you approach your doctors with this line of questioning: “help me understand,” they are more likely to remember that you are a partner to the process, not a threat to it.

It reminds the doctor that you are all on the same team – which you are! Doing what’s best for you and your baby. And not that they have to defend their decisions, their knowledge, or expertise.

I gave them my 2 power questions, these are much easier to remember than the BRAIN assessment and they open the conversation in a non-confrontational way.

The specific language of the questions also give the provider an opportunity to step into their human side.

Hospital care providers work hard to keep people safe and save lives. They are often overworked on crazy schedules and understaffed and under-resourced. It’s common for doctors and nurses to look at the case and follow the protocols, forgetting that the “primip PROM dec FHT” in front of them is actually a young woman and her husband, kind of shell-shocked, nervous for their babies, uncomfortable and displaced from their home, and unsure who they can trust.

The specific language of these questions serves to remind the care provider that she, too, is human, maybe a little tired, worried about 10 different patients and their babies, maybe a little “decision fatigued” and protocols and paperwork is a haven.

So, when you kindly, and with genuine curiosity, ask these two questions, it gives the doctor or midwife or nurse the opportunity to step out of the hospital staff mode and allows them to focus on you as a person, remember their own skills, thought process and their ability to think creatively about your situation.
It puts you all on the same tem and increases trust and communication.

So what are the two questions?

Why do you think this is necessary?

What would happen if we wait?

Remember, the language is key –

Why do you think this is necessary, not “why is this necessary” When making this a personal question, you activate a different thought process for the care provider.

You are inviting your provider to step out of “hospital protocol” and into being an individual making decisions about your care.

And that question can lead to other, deeper questions.

For example:
Doctor: We are going to start pitocin now.
You: Ok, why do you think that’s necessary? (Power Question 1)
Doctor: Well, you’re 40 weeks and your water broke and you’re not having consistent contractions.
(*now, here, you can ask further questions to clarify the doctor’s answer. You might ask if they are noticing any distress in the baby at this time, or what are the risks of pitocin, or will you be able to start at a very low dose, or is it possible to start with a different induction protocol, or you could even just ask, would you mind explaining that a little more? You should ask as many clarifying questions as you need to in order to understand the situation to your satisfaction.
Or, you could just move on to the next question:)
You: And what would happen if we wait? (Power Question 2)
(At this point I have noticed three categories of responses. And I will give examples of them below and how to interpret each answer)

Option 1:

Doctor: Well, we could wait another hour and see if your labor picks up on it’s own.
Interpretation: This is a course of action I believe will become necessary, but the situation is not an emergency and there is no danger in waiting. It may also mean that the situation can change with time and this course of action would end up not being necessary.

You might follow this up with: So if we decide to wait, what are we looking for? Is there anything we can do during this time to help us maybe not need the pitocin? We’d like to discuss this before we decide.

Option 2:

Doctor: We actually can’t wait, because there is meconium in the amniotic fluid and we don’t like the baby’s heart tones, so we need to get her out sooner rather than later.
Interpretation: I believe this is truly an emergency and you/your baby are in immediate danger.

You might want to follow up with: Do I have any other options? How many situations like this end in a c-section? Or if the baby is already in distress, can I request a c-section? We’d like to discuss this before we decide.

These are all options that you can discuss with your care provider)

Option 3:

Doctor: Well, you can wait if you want, but you might be putting your baby in danger if you do.
Interpretation: Generally, this means that the course of action is protocol and the doctor is required to recommend it and warn you of the dangers so they are not liable.

Another way to say this is that this is the CYA answer.

You might want to follow up with: We’d like to discuss this before we decide.

Once you feel satisfied that you understand what you need to about the recommended course of action, you can make a decision.
In any of the above options you can choose any of the following responses:

You: Okay, let’s go for it.
OR
You: I prefer to wait.
OR
You: I don’t consent to that course of care.

This sample conversation may not sound realistic because in most cases, once you open the discussion you will be interacting in a more human way than the words on this page! But these are just some ideas to get your mind working on how a conversation like this might go.

This is a non-confrontational way to gain more information and give you and your care provider the opportunity to think about the alternatives, and to truly assess how necessary it is.

Here’s another way to think about this.

Imagine you are a master baker. (I love this analogy because, well, dessert. Who doesn’t love dessert?! And babies are totally like dessert.)

Okay, you’re a master baker. You have been studying baking for years, your pastries are world-renowned, your confections are beautiful, and your cakes are like fluffy clouds.

You know your stuff!
You know measurements, how ingredients interact with each other, how they respond to different conditions like temperature and humidity, you also know exactly what to do if you need to tweak a recipe – let’s say there’s a butter shortage (true story!) and you have to use a different fat in your desserts.

You know your craft so well that you know exactly how to adjust the entire recipe and process so that you get a delicious dessert, even if it’s not exactly the same as the one you planned on making. You’re proud of the end result and everyone goes home happy.

Now imagine, you’re in the middle of making this modified recipe and one of the diners comes in and says they’re allergic to strawberries, which was not originally crucial to the recipe, but had now become a main ingredient!

So now you need to adjust on the fly.

What can you use instead?

Who can help you get this done?

Do you need to change the whole dessert plan to accommodate this change?

I’m going to add another element now. This scenario is happening on a cooking show with strict rules – you don’t follow the rules, you’re disqualified. Your reputation goes down like a fallen souffle.
The stakes are high.

Obviously, in health care, the stakes are much higher than desserts! But the reason I like this analogy, (aside from the chance to talk about dessert – yum!) is that I think it illustrates the thought process really clearly.
The desired end result is one where the dessert is tasty and the diners go home happy, even if it wasn’t the dessert you originally planned to make.

Power Questions

In birth care, the desired end result is the lowest possible infant and maternal mortality and morbidity rates. Which means that a year after you give birth, you and your baby are alive. That’s what all the protocols are designed towards.

So if you put yourself in your doctor’s head, using this analogy, she is looking at the situation in front of her and she knows how to achieve that outcome.

But your goal might be more complex than just being alive in twelve months from now.

Asking these questions is like taking a time out and allowing the care provider to think outside the “recipe” and look at the individual in front of them, not as an end result but as a partner in the process, with needs and desired results of your own.

When you build trust and open communication, in most cases you’ll find that you will create a team that keeps you solidly at the center of the experience and where you are all working together towards your shared goals.

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Success is not optional. You owe it to yourself and the people you serve.​

Ayelet Schwell