The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Getting a stubborn patient to say Yes

When a woman threatened to compromise her own and her baby's health, this doctor was able to defuse the situation with a "one-text" solution.

By Rajamalliga N. "Lee" Sharma, MD

[Ed. - This article is presented here for commentary and critique.  A first round of comments is offered by Janet Winters, a doula in Maryland.  These comments are in square brackets, preceded by "JW".  If you would like to add any comments, Please send e-mail to the editor.]

I walked into Labor and Delivery on a slow Sunday morning.  The board was empty, giving every indication that this would be a nice, calm day.

Then my partner dropped a bomb.

"A patient I've seen a lot of is coming in," he said.  "She's a previous section, and broke her water an hour ago.  You may have a tough time with her.  She's got a mind of her own and is bent on doing this her way."

I nodded and smiled.  "No problem."  Most people are fairly cooperative once they reach Labor and Delivery.  I didn't anticipate any difficulty.

That was at 9 am.  By 2 pm, the patient had not yet arrived, and I'd gone home to wait.  When I phoned the hospital at 3, a nurse told me that the patient had finally come in, but "just to have her cervix checked."  She fully intended to labor at home, and assumed we'd do what she asked and send her on her way.  At the time, according to the nurse's exam, she was dilated 1 cm.  Although she had been talked into seeing me, she'd refused admission, monitors, IV, even a hospital gown.  I told the exasperated nurse I'd be there momentarily.

As I climbed into my car, I thought about how I was going to handle the situation.  Fortunately, I had studied conflict resolution, and began to consider what course of action I could take that the patient might find satisfactory.

In conflict situations, many tools can be drawn upon to help resolve the situation and avoid making things worse.  In their book, Getting to Yes, Roger Fisher and William Ury describe a joint problem-solving process called the "one-text" procedure, which I thought might be effective here.  This method requires you to understand the other person's concerns, then address them by creating a detailed solution.  The solution is the one-text - a statement of goals and how to reach them.  It must be something the other party can respond to with either Yes or No.  The one-text approach leaves no room for negotiating or uncertainty.  If it's rejected, it must be revised until consensus is reached.  [JW - Actually, I thought this sounded exactly like what the woman had said to the nurses: "She wanted them to check her cervix, and then she wanted to leave."  Why didn't it work as well for her as it did for the doctor?  In reality, the only medical problem with her suggestion was that her cervix be checked, since that is the primary source of infection during labor.]  [JW - I am having some difficulty understanding the semantics of the one-text solution, i.e. what is the difference between negotiating, and revising a solution until consensus is reached.  Perhaps the difference is that the solution is revised only by the party "making the offer".  This sounds a lot more like bullying than anything else.]

What makes the one-text approach so effective in doctor-patient relationships is that it moves us away from trying to defend our point of view, and toward a more cooperative and sympathetic mindset in which we consider our patient's needs as well as our own.  It also encourages us and our patients to refine our ideas so we can reach an agreement based on mutual objectives.

For the one-text method to succeed, certain things should be avoided.

1.  Don't get angry.  The initial thought that went through my head when the nurse phoned me was, "How dare this woman!  Here it is, Sunday afternoon, I've been waiting for her since 9, and when she finally shows up six hours later and has the gall to order us around!"  [JW - Wow!  This makes it clear who's supposed to be running the show, doesn't it?]  I had to stop and remind myself that her behavior was not directed at me.  Patients who make these kinds of demands are usually trying to control the situation in an effort to keep their own fear in check.  Few things are as daunting as labor, especially for someone who has had a primary cesarean delivery.  [JW - Yep!  She trusted them before, and look where it got her.]  If I walked into that room irritated, I realized, all I would do is ruin the possibility of maintaining a good working relationships with my patient.  [JW - Well, it's nice that she's not such a bully that he doesn't want to maintain the appearance of the woman's being in charge.]

2.  Don't get pushy.  Back in the "good old days", the doctor's word was law.  If a physician said that jumping in the air three times induced labor, patients would be out on a trampoline.  But today we encourage patients to be active participants in their own care, rather than taking our word as gospel.  Although it's sometimes inconvenient and time-consuming, allowing the patient to participate in decision-making enhances the relationships between caregiver and recipient.  [JW - Hmm, this sounds good, but I don't see any point here where the patient's wishes affect management at all, other than that she isn't simply ushered into the operating room for a repeat section.]

3.  Don't counterattack.  I had to be prepared for the possibility that, because she was scared, this woman might hurl ultimatums and insults at me.  Such hostility, I reminded myself, wasn't a personal attack.  [JW - This is good; she realizes that most women are angry at ALL OBs and the system where they make all the calls, resulting in neonatal morbidity that is worse than all other industrialized countries, a cesarean rate that is twice that recommended by the World Health Organization, and an episiotomy/suture rate that clearly indicates that OBs simply do not value an intact perineum.  (Either that or they're truly stupid, and I simply don't believe the med. school taunts that OBs are in the bottom 5% of the med. school class.)]  By keeping a level head - and using humor, hand-holding, and other supportive behavior - I could prevent the conflict from escalating.

Part of understanding conflict is realizing that specific motives usually underlie another person's demands.  Designing the one-text with a contrary patient can help you understand what his or her motives may be.  On that Sunday, I began by unhurriedly taking the patient's history in order to get to know her.  I learned that she wanted a vaginal delivery because she hoped to return to her work as a missionary in South America as soon as possible.  I also found that she had tried to educate herself about active management of labor, but that her understanding of it was incomplete.  [JW - Which part - the part about more pain, higher cesarean rates, increased risk of fetal distress, postpartum swelling and subsequent engorgement/breastfeeding problems since pitocin in an anti-diuretic, or perhaps one of the other eddies in the cascade of interventions?)  Mentally, I adjusted my one-text based on her background.  Since she knew something about labor and delivery, I reasoned that she would cooperate with us if I explained, from a medical standpoint, exactly why certain things had to be done in order for her to have a healthy baby.  (Wow!  This doc really does think he's the omniscient God.  He implies that if she does what he suggests, he can guarantee a healthy baby; if she doesn't, her baby will be compromised.  How dare he talk in terms other than relative risk.  This case is particularly grating because the doctor's recommendations are not based on evidence: expectant management of ruptured membranes does not increase risk; there is also some good evidence that pitocin should not be used with a VBAC labor because it increases the risk of uterine rupture.  But, none of this matters when God is making the calls.)

"My two goals for you, which I believe you share, are, first, to have a vaginal delivery, if possible, and second, to have a healthy baby."  She nodded.  "Because you had a C-section in the past, specific risks must be addressed.  The most worrisome complication of a vaginal birth after a C-section is separation of the scar on the uterus.  The first indication of this would be an abnormality in the baby's heartbeat.  [JW - This, of course, is a gross lie.  What the good doc means is that this will be the first indication that standard management would notice.  She ignores the many other signs that typically accompany uterine rupture: pain experienced by mothers who aren't anesthetized; a shift in the baby's position as the baby is extruded into the abdomen; the accompanying shift in the way the baby feels on palpation and a corresponding shift in the place where the baby's heart is heard best.  This signs are only available through one-on-one attendance at a VBAC labor.  In addition, she shows a gross lack of understanding of the ways in which uterine rupture can actually be prevented:  avoiding pitocin and avoiding positions that are not upright.  A baby with the head well engaged in the pelvis cannot possibly be extruded into the abdomen.]  That's why continuous monitoring will be very helpful.  Also, since you're not having any contractions yet, we should consider low-dose Pitocin to start your labor; if we wait too long, we'll risk an infection from ruptured membranes.  And an IV would help protect you and your baby in the event of an emergency, which I hope won't happen."  [JW - Notice the smooth way the doctor sells the IV as a safety measure for the baby, rather than as something necessary for the administration of the pitocin.  Again, this is a lie.  A saline lock (so-called "heplock") would provide instant IV access if needed without limiting the mother's mobility.]  Having put my one-text solution on the table, I asked, "Are these things that you agree with and think you can do?"  [JW - Notice another smooth move - presenting compliance as a challenge whereby she can demonstrate her strength, rather than as her conceding to the doctor's demands and the doctor's  needs.]

Although this patient had adamantly refused attentive care minutes earlier, she now knew why such measures were critical to a safe vaginal delivery.  [JW - Again, this doctor has very limited understanding of either statistics or the English language.  Even if this approach made a difference in 5% of cases, would you call it "critical"?  I understand that the doc felt it was critical to her being able to justify her practice to her malpractice insurance carrier, but it was by no means critical to a safe birth.  In fact, many women with prolonged rupture of membranes give birth to perfectly healthy babies without pitocin inductions or antibiotics, and many VBAC moms have perfectly healthy babies without continuous monitoring.  In fact, shocking as it seems, some VBAC moms actually have completely unassisted births of perfectly healthy babies.  How, then, can this doc call these interventions "critical"?  They certainly make me feel critical, but they are not critical to the birth of a healthy baby.  This doctor either doesn't know her research or she's a master manipulator with no conscience.  Neither of these is a particularly appealing characteristic in a birth attendant.]

Although this patient had adamantly refused attentive care minutes earlier, she now knew why such measures were critical to a safe vaginal delivery.  [JW - And can you believe the way this doctor calls IV lines, drugs and continuous electronic monitoring "attentive care"?  To me, attentive care means that the care provider actually stays in the room with you, as in "attending" the birth, which, by the way, is originally derived from the sense of "attend" meaning "to wait".  Obviously this doc has revised the meaning of attentive care 180 degrees.  "We'll attend you by NOT waiting."]  Her demeanor suddenly altered.  No longer the stubborn, difficult patient who had so frustrated her nurse, she answered my question with a simple, "Yes, I can."  She was placed on a monitor, received an IV, and was started on Pitocin.  Four hours later, I delivered her healthy baby boy vaginally.  [JW - Well, here we get to the crux of the situation.  All along, this doc has considered the woman's desires simply to be an obstacle to THE DOCTOR'S delivery of the baby.  Well, why not just get it out in the open to begin with and tell her that it's YOUR birth and YOUR baby, and once they've given the stamp of approval, she will be allowed to take the baby home for safekeeping if the hospital staff are happy with the way things are going.]  A situation that was potentially rife with conflict was resolved in a constructive way and resulted in a very positive experience for both patient and physician.  [JW - Does anyone here believe even for an instant that she went back to the woman's room the next day, after she'd had some rest, and asked her how she felt about having her plans overruled?]  Perhaps the most important lesson was that conflict itself presents a valuable opportunity to become better and more creative.  [JW - Better?  How?  By listening to the woman and reading the research that SHE has read?  Or by becoming more adept at manipulating a woman during one of the most vulnerable periods of her life?  I don't know about you, but when I was a child, that kind of treatment was called bullying, and it wasn't considered very nice.]  If we can approach conflict without fear, the possibilities are endless.

[JW - Wow!  I think what this doc really means is that if you assume that you will get your way in the end, there is no limit to the range of objections you can overpower.  I'm sure her list of acceptable possibilities was actually quite limited and did not include "letting the woman" have her own way.]

[BM - I would like to comment on the article by the Doctor who managed to tame a non compliant patient. I only hope I can keep the comments from singeing the page.]

This article was an object lesson in why every woman needs a well-educated doula if she has any hopes of having a drug-free birth.

Medical Economics - Obstetrics-Gynecology - October 2000, p. 80.