The Birth of Donatella Denovo
The Birth of Donatella Denovo
John LeMasney
Rider University
June, 2008
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The Birth of Donatella Denovo
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Introduction
This case will look at the conflict narratives of James and Dana, who are 2 expectant
parents in the final stage of pregnancy, the maternity staff of the New Mexico Medical Center,
and the staff of the Albuquerque Midwifery regarding the imminent birth of the couple's second
daughter, Donatella. I will introduce each party and each point of view in order to tell the whole
story of the conflict. I will describe a few specific interrelated conflicts that might have
benefitted from mediation. I will describe the mediation process that might have benefitted these
parties to work through the conflict in terms of physical design, ideological design, mediation
models, disputant realities, and a variation on managerial third party style mediation that might
more suitably meet the special needs of a medically oriented mediation. Finally, I will look at the
outcomes in reality, and how those outcomes might have been the same or different with
mediation.
Background
James and Dana want a natural, vaginal birth, without anesthesia, with minimal monitoring, and
without inducing labor, if at all possible. The parents want a healthy birth and have taken great care
to protect the health of the baby throughout pregnancy. Dana wants to be able to move around, to
give birth standing up, and to utilize the spa and other amenities at the hospital, in order to
experience as close to a natural process as possible. Dana's first child was delivered in a highly
medical way, under anesthesia, via Cesarean section, on a prescheduled date, due to a diagnosis of
placenta previa (partially occluded cervix) that was criticized afterwards as being "overly cautious"
by the midwifery. The first birth was performed at another hospital, and this hospital was chosen
because of its willingness to work closely with the midwifery. Dana also wants to avoid the breast
latching issues she encountered with her first child’s birth, which she and her husband feel is the
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result of Dana’s separation from the baby because of her anesthetic state immediately following the
first pregnancy’s surgery, which required her to recoup for a while after birth away from the baby.
They are looking for minimal medical intervention, and would prefer to have this baby in a birthing
center or even at home, but because insurance does not cover these options, and because of the risk
of complications in natural births following cesarean sections, James and Dana opted to use the
hospital's facilities for safety's sake. This is complicated by the fact that Dana's first delivery was a
Cesarean section, which typically results in Cesarean sections for subsequent births. Dana and
Donatella are both healthy; Dana has progressed 9 months, and has been going for checkups at the
midwifery weekly.
The midwifery works to protect the interests and wishes of the parents in their quest of a natural
birth. Midwives are an alternative to doctors in birth, and can help couples avoid hospitals entirely
in some cases. Midwives often work as liaisons between medical staff and naturally oriented
parents, reducing contact and only pulling in doctors when something beyond their licensed ability
is called for, such as surgery. By their experiences with hundreds of VBAC (vaginal birth after
cesarean) births, reducing medical interventions, and delivering often outside the presence of a
doctor, they gain insight into when it is necessary to intervene with the natural process, introduce
unnatural techniques as intermediary measures as necessary, and prevent or work through
complications as they arise. The midwifery agrees that Dana is a good candidate for a successful
VBAC delivery, but as always recognizes and promotes that when dangers to the mother or child
are perceived, that the proper medical interventions must be considered. Generally, midwives are
not hospital staff, and are seen as professional visitors who have the right to practice, but must defer
to a doctor’s decision if there is a dispute.
The medical staff (by which I mean maternity nurses, doctors, and administrators) want nothing
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more than a healthy baby and mother. They want a successful birth, and want the birth to happen
without complication, danger, or risk. Medical procedures have been developed over time to reduce
risk, solve the problems of traditional birth (e.g., pain, death of mother, child, or both, disease and
infection) and make birth just like many other standard procedures. These doctors see the negative
results of waiting too long to intervene when an issue shows itself in labor and birth. Children can
become brain damaged, poisoned, or stillborn if action isn't taken and so when there is a medical
solution to an obvious problem, there is concern when that action isn't quickly taken. Insurance
rates and costs to the hospital and staff are exorbitant and can effectively shut down hospital
operations if a malpractice suit shows that doctors didn't act as soon as an issue was apparent.
Interdependent conflicts
Dana's water has broken, which is medically referred to as a spontaneous rupture of
membranes. It is one probable sign that birth is imminent, either naturally or by medical
intervention. Dana and James are excited and surprised by the event, but since they had been
waiting for nine months, were not too surprised. When they called the midwifery to report the
water breaking, the midwife suggested that they stay where they are, see if labor progresses, and
if nothing else happens before the next morning, to visit the hospital for a checkup at 10 am.
Dana is having pre-labor contractions, but nothing resembling labor. At the meeting the next
morning at the hospital, Dana is happy, still having irregular contractions, and is looking forward
to returning home to continue progress towards labor in peace. During the visit with the midwife,
in which it's agreed that Dana should go home and return later that afternoon to check into the
hospital as a patient, a doctor on staff hears that Dana’s water broke and decides that it is in the
best interest for Dana and Donatella to stay at the hospital and begin monitoring. Dana begins to
cry at the thought of not being allowed to continue progress at home, which is about 20 minutes
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away. Threshold issues for Dana and James include being able to stay home as long as possible,
so that the medical environment of the hospital does not interfere with Dana's relatively calm and
peaceful vision of progressing towards labor. Threshold issues for the medical staff are that once
the water has broken, there is an increased chance for infection for both the mother and child,
and that taking this chance (leaving the hospital for a few more hours) might result in a disaster.
Threshold issues for the midwifery are that as long as the mother does not have a temperature or
other sign of infection and that regular labor has not begun, that the mother should be in a restful
place, which in this case, is not the hospital. A mediation session might have helped the
disputants arrive at the agreement they devised in a less anxious way. At the midwife's urging
with the doctor, the agreement is that Dana is allowed to go home, as long as she agrees to return
before 24 hours have passed since Dana’s water broke. The 24-hour mark is a key time at which
labor usually starts naturally after the breaking of water, without which medical intervention is
usually suggested. The couple returns later that evening before the 24-hour mark, with the
knowledge that they will have to check in Dana, but hoping that birth will be allowed to continue
naturally. When Dana is checked and it is determined that she has not progressed significantly,
the midwife suggests that Dana be allowed to continue natural progression. The doctor on the
floor hears about this and suggests that Dana prepare herself for a second cesarean, since natural
progression is happening so slowly. The fear is that with the breaking of water, there is a risk for
an increased chance of infection, but the midwife argues that since no fever or other sign of
infection has appeared, that Dana should be allowed to continue on a natural path. The doctor
reluctantly allows this order to stand, and Dana and James are very relieved that they chose to
use the midwifery.
After 36 hours have passed without significant progression in terms of dilation, doctors
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are now actively concerned and arguing for either induction of true labor by chemical means,
such as Pitocin, or for Dana to agree to a cesarean. Dana is now having regular contractions, and
is considered to be right on the verge of active natural labor. The couple is also feeling very
stressed by the regular entrance of doctors, midwives, nurses, and other staffers which she had
been hoping to avoid by progressing until full-on labor at home. Dana feels that the stress of
interruptions is affecting her ability to progress naturally and regretfully wishes she had simply
stayed at home. The doctors are relieved that Dana is being monitored and that if a complication
arises that the baby will have the best chance of recovery from the complication. Dana still does
not have a fever, but is now actively monitored all the time, which she agreed to in order to
continue laboring naturally. Thus, her wishes to be free to move about are compromised, which
she also feels is affecting her ability to concentrate on labor. The doctor wants to administer
Pitocin to speed labor along, so that in the next few hours, a decision can be made about natural
birth or cesarean delivery.
Threshold issues include the fact that Dana knows about the painful contractions
associated with Pitocin, the increased chance of the previous cesarean seam ripping with these
stronger contractions, and that Pitocin usually requires an epidural to be administered, which is
another procedure that Dana had hoped to avoid, as she wished to experience the natural pain of
motherhood as a way of embracing the natural experience. Mediation might have helped the
disputants arrive at the agreement they found in a collaborative way instead of arguing their
points of view in competitive stances. At the indication by the midwife to Dana that this
intervention provided an opportunity to continue natural progression, Dana reluctantly agrees to
the epidural and low dose Pitocin in the hopes that after a few hours dilation will have
progressed, and natural birth will still be able to happen. The nurses and doctors are relieved, the
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midwife is concerned that Dawn’s rights were compromised, and Dana and James are becoming
depressed. After 46 hours since Dana’s water broke, new concerns appear. Dana has contracted a
small fever, Donatella has begun showing an increased heart rate at the wrong time in
comparison to contractions, and the doctors are repeatedly reminding Dana of the concerns and
complications that could occur if she doesn’t agree to a Cesarean section right away. Dana is still
not progressed enough to foresee a quick natural birth. Crying, exhausted, and feeling defeated,
Dana agrees to the cesarean section.
Donatella is born almost exactly 48 hours after the breaking of water. She’s healthy,
crying, and almost 10 pounds. The doctors are very happy with the outcome, the midwife feels as
though this outcome had to happen at the appearance of the latest complications (fever, heart
beat issues), and James and Dana, while thrilled at the health and well being of Donatella, feel
that they have spent the last two days fighting for their rights. The doctor who performed the
cesarean says to Dana that she knew that the cesarean section was going to happen and wished
Dana had simply agreed sooner. Dana does not speak to the doctor again during her stay and
chooses to attend follow up visits with another hospital.
Design of Mediation
A mediation program for hospitals might be a very good way to deal with some of these
relational issues in a deeper way. Much like the managerial third party model described in New
Directions in Mediation (Karambayaa and Brett, ch. 9, 1994) this model would rely on mediators
who exist on staff, not primarily as mediators, but with mediation as a secondary role. I call this
model the Specialist Mediator because it describes people who are primarily skilled in their
organizational expertise, but called on to mediate organizational and customer relational issues
using additional mediation training skills, making them especially useful in their specific field as
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mediators due to their depth of knowledge of the related issue. While this could easily be
criticized as limiting the scope of issues which the specialist mediator could mediate at this level,
it would provide a mediator who has additional contextual understanding and vocabulary to
engage at a deep level with professionals such as surgeons. Differences in the realities of the
disputants, the relative rank of the various parties, and the significance of each disputant’s level
of respect for the others all point to a need for a neutral third party to help disputants be heard
and fully understood. The mediation space might be located somewhere in the hospital or even in
a separate building, but in the case where a birth is taking place moving the mother and doctors
to a separate space might not be available as an option. For example, the mother may not be in an
ambulatory state, may be in active labor, or may be unable to be out of range of monitoring
instruments. I think that in this case, the mediation space would have to be the hospital room.
There might be a special orange doorknob hanger that would indicate that mediation was going
on in the room, and that a certain level of emergency would be required to interrupt it. This
would provide the safe, quiet, uninterrupted space that mediation requires (Domenici and
Littlejohn, 2001).
Mediators would not be volunteers, but rather would follow a variant of the managerial
third party model (Karambayaa and Brett, 1994), in which several key hospital staff would have
it as a primary responsibility to provide mediation services for a department. In each case, the
mediator would have to be knowledgeable about the happenings of the department so that in
cases where an emergency was looming, the mediator was not spending time finding out what
procedures were available to counter the emergency. I think also that the managerial third party
would have to have mediation training, so that they would provide the safe environment,
collaborative communication, power management, process management, and face management
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that define the characteristics of constructive mediation (Jones, 1994, p. 46).
Introductions would emphasize the point of transformative mediation, that is, to relate.
Also emphasized would be the empowerment of patients in a situation where patients might feel
very intimidated in the presence of doctoral authority and experience (Jones, 1994, p. 34).
Caucuses would be a major part of progress in this case, because of the length of time involved,
the sensitive nature of the content, and the relative mismatch in authority between the doctors the
midwives, and the parents. Confidentiality would definitely be compromised because of the
nature of the records generated with every change administered to patients. Each time Dana was
given an extension to progress naturally, for instance, it was noted and signed by a representative
of the hospital for the sake of posterity and ethical-legal concerns. Ground Rules would include
all of the standards of mediation, such as one person speaking at a time, active listening, and no
cursing or name calling (Folger and Jones, 1994), but would also likely have very specific
contingent rules based on this case, such as no threats, no indication of one’s feelings about
malpractice or parenting skills, and no warnings of bad outcomes (brain damage, blood
poisoning) without citable precedent. In terms of presence, I think that aside from the managerial
third party, a co-mediator (unaffiliated with the hospital), a midwife representative, a doctor
representative, the nurse, and the parents would all be present in order for mediation to happen. I
think that sessions would last no more than thirty minutes at a time, given the nature of the
workplace. I think that these thirty minute sessions could happen several times in a day, and
could be supplemented with caucuses.
The Interpretive Model (Littlejohn, et al., 1994, pp. 70-83) provides a way for us to
analyze disputant realities and how they might have been underlying this conflict. A mediation
session might benefit from these reality assessments in choosing mediation approaches and
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models (Littlejohn, et al., 1994, pp. 70-83). In terms of Moral Reality, the parents are
expressivist. They believe that morality is theirs to define and express as they see fit as
individuals. Morally, the doctors are republican and (much less) utilitarian, in that they are
working for the greater overall good, and working to negotiate answers and agreements that meet
the needs of a given problem while meeting needs of individuals when possible (Littlejohn, et al.,
1994, p. 70). In terms of Conflict reality, the parents presumed that given their intent for a
natural birth in a hospital that they would encounter resistance in their quest, but they also see
conflict as a necessary, beneficial way to work through differences in order to achieve the goal of
a natural birth in a safe environment. The parents prefer Conflict Management, and specifically
the models of conflict maintenance, in which conflict is healthy and managed, and also the
economic bargaining model in which conflict can generate opposing options that can be worked
with or negotiated in order to achieve goals (Littlejohn, et al., 1994, pp. 71-72). The doctors
prefer a reliance on outside parties, specifically the adjudicative model in which a higher
authority, such as the hospital administration or the issuers of the doctoral license, would decide
that the conflict be resolved in a particular way (Littlejohn, et al., 1994, pp. 71-72). In terms of
Justice reality, the parents are likely to prefer distributive: entitlement justice, in which they get
their best outcome as entitled to them as parents (Littlejohn, et al., 1994, pp. 72-73). They should
get to choose the handling of their daughter’s birth in the way that they see fit, because it is their
daughter. The doctors might have a justice reality of distributive: social welfare, because they are
most concerned with the greater good, the ongoing best outcomes, and the overall benefits of all,
despite the possible losses at an individual level (Littlejohn, et al., 1994, pp. 72-73).
The midwives have a moral reality of utilitarian and expressivist, which allows them to
represent the interests of their individualistically minded patient base. Midwives have a conflict
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reality of conflict management and economic bargaining model, in which they are constantly
negotiating and aligning the views and interests of their individualist patients and the medical
and health reality of the medical history, practice and authority. In terms of justice reality, the
midwives maintain a social welfare justice view, in which each participant is ideally given what
they need. They try to maintain the health and safety requirements of the medical tradition while
allowing parents who are interested in a natural birth the opportunity to pursue that as safely as
possible. Natural birth is full of uncertain outcomes, and the medical tradition solves many of the
problems of natural birth at the cost of the natural experience. That problematic stance and
relative cost is regarded differently by each of our disputants (Littlejohn, et al., 1994, pp. 70-74).
I think that what the Interpretive model tells us about this case above all is that the
parents are thinking mostly of themselves, and the doctors are thinking mostly of the benefits to
humanity in general, and that relationally, focusing on the space in between those extremes,
probably by using circular questions and reframing techniques, would be a beneficial tactic for a
mediator. The midwives are often acting as untrained specialist mediators in this case, pursuing a
balance between the greater social needs of the medical view and the more self centered
individualist view of the naturally minded parents.
Hofstede's Model also provides an interesting method for analyzing these disputants
(Donahue and Bresnahan, 1994, p. 146). The parents are low power distance. They would prefer
that they make their own decisions, control outcomes, and be able to make choices. The doctors
would prefer a high power distance, where their knowledge and expertise are unquestioned,
provide the decisions, and are the final say in medical matters. This is a major source of conflict
in this case. The parents are low uncertainty avoidance – they have a wait and see approach
throughout, hoping to let events unfold as they happen. The doctors have a high uncertainty
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avoidance – they would prefer to know the date and time of the birth well before it happens, and
in general would like to know and foresee as much as possible about all aspects of the pregnancy
and birth, through documentation, checks, balances, and charted progress. You can see how this
too has a large impact on the conflict in this case. In terms of individualism, the parents are
highly individualistic, as we saw in the application of the Interpretive model. The doctors would
prefer conformity and collectivism. When a decision or order is questioned, it brings uncertainty,
more questions, and possibly endangers patients. In terms of femininity, the parents are more
compassionate, nurturing, and sensitive, while the doctors are more masculine, problem solving,
and determinate. From every possible perspective provided by Hofstede’s model, the parents and
the doctors are at odds, and have a high likelihood of conflict. The midwife would be low power
distance, high uncertainty avoidance, high individualism, and highly feminine. In this way they
provide a nice mixture of the Hofstedean dimensions of the other disputants, and often worked as
pseudo mediators in this case, meaning that although they are not trained in mediation, nor
actively aligned with the idea of either relational interactions or problem solving, they end up
doing both of these things in caucuses and in multi disputant meetings throughout the case. The
Interpretive model and Hofstede’s model both show why this is possible, in that the midwives
hold and understand a mixture of stances held by disputants, and provide a bridge of
understanding between the various realities and stances of the disputants. For example, in the
first conflict, where Dana is asked to stay at the hospital but wishes to go home, the midwife asks
the doctor to reconsider the order so that Dana can act on her wishes as long as she returns within
a reasonable amount of time. Dana and the doctor agree. It might be interesting to see what
might have happened if the midwife had not acted as mediator in this case.
One other way in which we can analyze the interdependent nature of this conflict is to
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apply the Interdependent Sequence of Interactions. The SIS model is a series of interrelated
triads of communication containing each party’s relative context, communicative act, and goal in
order to determine why certain communicative acts result in expected or unexpected outcomes
(Millen, 2008).
For instance, we can look at the entry point of the conflict just mentioned and escalate it
very quickly without the benefit of the midwife’s pseudo-mediation. Dana is asked to stay at the
hospital despite wanting to go home and progress naturally. After coming in for a checkup after
her water has broken, Dana asks to go home (act) in order to progress naturally in a quiet
comfortable space (goal) because in her mind, she is progressing well in terms of natural birth
(context). Dana’s act of asking to go home prompts a new context for the doctor that going home
could put the baby in unnecessary danger (context) to which the doctor decides to ask Dana to
stay (act) in order to keep the baby safe (goal). Dana responds to the idea of being asked to stay
in the hospital instead of going home (context) with fear and withdrawal, which causes her to
protest and suggest that she may go home against medical advice (act) in order to convince the
doctor of her seriousness with which she regards the ability to go home to progress naturally.
The doctor sees the new possibility of Dana leaving as a direct threat against the baby’s health
(context), and calls security to watch Dana (act) with the intent of protecting the baby (goal).
James sees security arrive (context) and begins to protest the state of affairs (act) in order to
prevent Dana from being held against her will. The security officer sees James walking towards
her (context), brings out her stun gun (act), with the hope that James will see the error of his
ways (goal). Luckily none of this actually happened, but when we do not relate to each other’s
best intentions, messages can quickly become misinterpreted, in this case perhaps leading to a
crisis.
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Resolution and conclusion
According to both the context of these conflicts and the content of the disputes, perhaps
the best mediation model would be one of the Specialist Mediators acting in the Interventionist
style. One very strong commonality in this case is that all stakeholders are very much interested
in Donatella being born safe and healthy. The interventionist style of mediation would provide
the mixture of individualist and collectivist views with the power to strongly suggest solutions
that would be in Donatella’s best interest, providing agreements much like those that were
agreed to through a much more difficult process. If a specialist mediator had intervened in the
Pitocin conflict by saying: “Here are your options – you can leave against medical advice and try
to have the child at home, which we strongly advise against, you can consider a cesarean section,
or we can introduce Pitocin at a low rate, monitor your temperature and the baby’s heart rate, and
we can assess again in four hours. At that point, if no progress has been made, a cesarean will be
the only remaining option. If a fever shows up before then, we will immediately move to a
cesarean section. What would you like to do?” I feel that this kind of brainstorming, providing
options, and balancing the ridiculous (leaving) with the comparatively sublime (4 more hours)
while maintaining safety for Donatella (at the appearance of a fever we have to operate) would
have been much more successful in performing relational transformative mediation than to have
these Hofstedean opposite disputants trying to work out agreements while running in opposite
directions.
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References
Domenici, K., Domenici-Littlejohn, & Littlejohn, S. W. (2001). Mediation: Empowerment in Conflict
Management, Second Edition (2nd ed., p. 198). Waveland Press.
Donohue, W. A., & Bresnahan, M. I. (1994). Communication Issues in Mediating Cultural Conflict. In
J. P. Folger & T. S. Jones (Eds.), New Directions in Mediation: Communication Research and
Perspectives (pp. 135-158). Sage Publications, Inc.
Jones, T. S. (1994). A Dialectical Reframing of the Mediation Process. In J. P. Folger & T. S. Jones
(Eds.), New Directions in Mediation: Communication Research and Perspectives (pp. 26-47).
Sage Publications, Inc.
Karambayya, R., & Brett, J. M. (1994). Managerial Third Parties. In J. P. Folger & T. S. Jones (Eds.),
New Directions in Mediation: Communication Research and Perspectives (pp. 175-192). Sage
Publications, Inc
Littlejohn, S. W., Shailor, J., & Pearce, W. B. (1994). The Deep Structure of Reality in Mediation. In J.
P. Folger & T. S. Jones (Eds.), New Directions in Mediation: Communication Research and
Perspectives (pp. 67-83). Sage Publications, Inc.
Millen, J. (2008, June 10). Interdependence of Sequential Interactions. Presented at a COM 390 lecture
at Rider University.