[CEG]

I am an aspiring L&D nurse, student nurse and doula... and I need your help again.

I had a doula client last night, third child but first two were precipitous premature births. Mom was 3 cm and admitted for induction because baby was posterior so if anyone has any insight into that I would love it.

As mom was pushing baby's HR was dropping, eventually getting to the low 80's when doc decided to cut an epis and use a vaccuum. This was after about 45 minutes of pushing. The baby's head was just visible.

Prior to this I suggested we change positions to try to help HR, speed pushing. I was thinking side-lying or hand and knees. This was immediately rejected by nurse/doc because "we don't do that" and "the bed is already broken down."

Wondering if my suggestion was crazy, out of line, wouldn't have been effective, etc. Just wondering if you could provide some insight. I have seen it used effectively at other births at the CNM suggestion so I thought it was a valid suggestion before epis/vacuum. I find it difficult to argue with the staff who obviously have mom/babe best interest in mind but sometimes don't want to depart from standard procedure. The nurse was truly wonderful aside from this. Thanks for your input!

[Jolie]

Originally Posted by CEG

I am an aspiring L&D nurse, student nurse and doula... and I need your help again.

I had a doula client last night, third child but first two were precipitous premature births. Mom was 3 cm and admitted for induction because baby was posterior so if anyone has any insight into that I would love it.

As mom was pushing baby's HR was dropping, eventually getting to the low 80's when doc decided to cut an epis and use a vaccuum. This was after about 45 minutes of pushing. The baby's head was just visible.

Prior to this I suggested we change positions to try to help HR, speed pushing. I was thinking side-lying or hand and knees. This was immediately rejected by nurse/doc because "we don't do that" and "the bed is already broken down."

Wondering if my suggestion was crazy, out of line, wouldn't have been effective, etc. Just wondering if you could provide some insight. I have seen it used effectively at other births at the CNM suggestion so I thought it was a valid suggestion before epis/vacuum. I find it difficult to argue with the staff who obviously have mom/babe best interest in mind but sometimes don't want to depart from standard procedure. The nurse was truly wonderful aside from this. Thanks for your input!

Unless the mom had an epidural that prevented her from safely changing positions, I see nothing wrong with your suggestion.

Frequent position changes during labor and pushing are an accepted intervention in attempting to "bring" a baby into a more desirable position for delivery. The explanation that "We don't do that, or The bed is already broken down," sounds much more like staff and physician convenience than any medical contra-indication to your suggestion.

As long as the baby was tolerating continued labor, I think it is a shame that your suggestions weren't attempted.

[rpbear]

I think the difference is that in other births you said the CNM suggested the possition change, you are dealing with a MD in this delivery. I work with some MD's who are willing to do things slightly out of their comfort zone, but I also work with MD's who ALLWAYS want the pt in stirups, the bed broken down, the bed in a very high position, the MD on a stool at the perineum waiting for the baby. I have had deliverys that are going very fast the head is already crowning and the doc is insisting that the bed be broken down and the legs in stirrups....HELLO the head is coming out!!! Just catch the baby!

Your suggestion was not totally out of line, however there are health proffesionals, RN's, MD's and CNM who may feel like you were underminding their judgment and stepping on their toes.

As for why she was being induced, I don't get it either. If the pt didn't want to be induced she should have said something. As long as baby and mom are fine there should have been no reason to admit her and induce. We get some strange reasons for induction also.

[bagladyrn]

I could be just a case of "we always do it this way", but it could also be a valid case of fetal distress and a need to get the baby out quickly - HR in the 80's - for how long, how related to the contractions, what had the previous strip looked like, variability, accels, etc. It's really hard to judge this without being there/seeing it. I would hope though that the provider or the RN would take the time afterwards to explain to you and/or the patient what they were seeing and why they proceeded as they did if there were not time for explanations beforehand.

[Jolie]

Originally Posted by bagladyrn

I could be just a case of "we always do it this way", but it could also be a valid case of fetal distress and a need to get the baby out quickly - HR in the 80's - for how long, how related to the contractions, what had the previous strip looked like, variability, accels, etc. It's really hard to judge this without being there/seeing it. I would hope though that the provider or the RN would take the time afterwards to explain to you and/or the patient what they were seeing and why they proceeded as they did if there were not time for explanations beforehand.

But the OP indicated that her suggestions were discounted BEFORE the baby's heartrate dropped. That's why I agree that she was "brushed off".

Had she suggested position changes to rotate the baby during a run of fetal bradycardia, I would wholeheartedly agree with the need to proceed first and answer questions later.

[CEG]

Thanks for the input. I have learned since that the fluid was low so that was the main reason for induction. They did a biophysical profile because the doctor apparently had trouble finding the heartrate. To be honest, it sounds like the doc was looking for a reason for an induction b/c he was already pressuring mom to schedule and this was on her due date.

I was trying to be nonconfrontational so I turned to the nurse and quietly (so the mama wouldn't hear if she said no) "Could we try pushing in another position? Maybe on her side?" when I got my answer. Was there a better way? I really want to work well with the staff. And this was a great, supportive nurse.

[Jolie]

Originally Posted by CEG

Thanks for the input. I have learned since that the fluid was low so that was the main reason for induction. They did a biophysical profile because the doctor apparently had trouble finding the heartrate. To be honest, it sounds like the doc was looking for a reason for an induction b/c he was already pressuring mom to schedule and this was on her due date.

I was trying to be nonconfrontational so I turned to the nurse and quietly (so the mama wouldn't hear if she said no) "Could we try pushing in another position? Maybe on her side?" when I got my answer. Was there a better way? I really want to work well with the staff. And this was a great, supportive nurse.

I think you did fine! By speaking quietly and privately to the nurse, you avoided putting anyone on the spot. Since you were so considerate of the nurse's preferences, perhaps she would be willing to set up a time to spend a few minutes with you to discuss the "ways" of the unit, and help you to devise a plan to work in patient preferences without compromising safety, or stepping on the toes of the staff and OBs.

I'm sure that with time, you will find nurses who will become very strong allies!

[midwife2b]

You can come be a doula with me anytime!