appropriate positioning changes during labor

  1. allo all--new grad here with another exciting question to all you wizened ones of obstetrics--

    at what point do you want mom to be able to squat or raise head into high fowlers when pushing to avoid having the cranial/pelvic collision ( like my med term? i made it all by myself...)


    I am still in orientation ( thank goodness, however not for much longer*yikes*) and when I am independently pushing with my couple they ask if she can raise the head of the bed, and I only do so minimally until mom is comfortable until i see hair through the bulge...is this too long?

    also, what is the primary reason for a fetal descent resulting in an acycnclitic presentation? what type of distress can this cause?

    also one more thing here, when we are worried about water intox. with pitocin, when have you seen it manifest? are we talking second day induction?

    and finally...what do you do about those darn snotty nurses who think you have one brain cell because your name tag says graduate nurse????grrr...that's not really a question here...i know I just gotta stiffen up a bit, but man, petty petty petty....

    again, another incredibly effective lesson on how NOT to be once I pass my boards...i CAN"T wait until i get a student following me around....( i mean give me a year though, k)??


    thanks ya'll----joy:kiss
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  2. 9 Comments

  3. by   shay
    Joy, you're so sweet....

    I'll try to answer 2 of your questions. I dunno the answer to the pitocin water intox. thing as to when it manifests. Sorry!

    Anyhoo....on to what I can answer. The pushing thing...
    Well, as always with OB, that depends... If they have an epidural, well, I sit them up high about 30 min. before I start pushing, actually...helps labor the baby down, and also works that gravity action to drag that ropivicaine to the PERINEUM where they're gonna NEED it!! LOL!! If they want to sit up or squat while pushing in the first stage(of pushing), fine. I let them as long as they are pushing effectively. If the head is just not budging past that pubic bone, well, an old old (I'm talking YODA old) OB nurse taught me to lie the patient almost flat and push with them that way, and the head magically turns the corner. Um, does that answer your question??? I know I tend to get diarrhea of the fingers...

    The acynclitic thing...I most often see this in a woman who gets an epidural when the head is either too high or in an acynclitic position prior to the epidural and she has not been moving around/changing positions/walking. Most often, though, I see it when the epidural goes in before the vertex has descended to about -1. Think about it.....tight, tense patient...vertex in the stratosphere...pt. gets epidural...pelvis relaxes when pt. relaxes...head in the clouds descends at whatever angle it was suspended, and that could be anything. BUT THAT'S JUST MY EXPERIENCE.

    Okay, gonna shut up now. Diarrhea of the fingers getting out of hand....
  4. by   joyrochelle
    so basically i have been seeing patients on too much pitocin ( becasue they can't get off of the monitor long enough to let the descent happen with gravity) and epidurals way too early??? Man oh man...so much to learn...and my dumb butt has a terrible time making generalizations cuz " everybody is different"! i know i know..it will take time...hasn't three years of being a student stand for anything???? * smirk*



    ps...I'm sweet?? really? awww...thanks shay....
  5. by   HazeK
    OK, I've done L&D x 21 years now and have never seen "water intoxication from pitocin"!

    What I HAVE seen is patients who are overloaded with fluid and start 'third spacing' the fluid into their tissues (edema, swelling), and acute pulmonary edema. So, keep track of I&Os accurately, even on low-risk patients. (are there really such things as low risk patients?? Hmmmmm)

    The really-old-timers tell me that Oxytocin used to be made from desicated pituitary glands from cows (we are talking WAY back there) and that they used to see water intox. with pitocin, then....but not now with the chemically manufactured stuff!

    Another consideration: What solution are you using???
    We have doctors who order 30 Units to 1 Liter fluid and those who only order 10 Units to a liter. Needless to say, a woman on 20 mU/min gets ALOT more fluid from the more dilute solution!

    Does this help???

    Haze
  6. by   HazeK
    The pushing thing...

    Have to agree with these points from Shay:

    "If they have an epidural, I sit them up high about 30 min. before I start pushing, actually...helps labor the baby down"

    our beds will go high HOB up and then we put the bottom of the bed down... the bed ends up looking like a throne, so we call it "Queen's Chair" position!
    It works well!

    Shay also said: "If the head is just not budging past that pubic bone...lie the patient almost flat and push with them that way, and the head magically turns the corner.

    Also, try 'lightening up' the epi dose when it is close to time to push. I like my patients knowing when they are contracting (vs numb to the boobs) and even complaining a bit about the increased rectal pressures....our anesth guys will stand by w/ a quick 'top off' dose when the pt is begining to crown, so the delivery is comfortable. This is esp. true for first time moms...and, not so much for the "pros".
  7. by   HazeK
    Again, cudos to Shay, who wrote:

    "The acynclitic thing...I most often see this in a woman who gets an epidural when the head is either too high or in an acynclitic position prior to the epidural and she has not been moving around/changing positions/walking. Most often, though, I see it when the epidural goes in before the vertex has descended to about -1. Think about it.....tight, tense patient...vertex in the stratosphere...pt. gets epidural...pelvis relaxes when pt. relaxes...head in the clouds descends at whatever angle it was suspended, and that could be anything. "

    it often goes back to this question:
    DO YOU WANT TO BE A GOOD NURSE? OR A NICE NURSE?

    a good nurse would wait for the epidural until the Vertex is well positioned and -1 to 0 station....a nice nurse wants the patient to like her ....

    you can only pick one answer!! :-)
  8. by   joyrochelle
    very helpful! thanks very much! luv--joy
  9. by   shay
    Originally posted by HazeK
    OK, I've done L&D x 21 years now and have never seen "water intoxication from pitocin"!

    What I HAVE seen is patients who are overloaded with fluid and start 'third spacing' the fluid into their tissues (edema, swelling), and acute pulmonary edema. So, keep track of I&Os accurately, even on low-risk patients. (are there really such things as low risk patients?? Hmmmmm)

    The really-old-timers tell me that Oxytocin used to be made from desicated pituitary glands from cows (we are talking WAY back there) and that they used to see water intox. with pitocin, then....but not now with the chemically manufactured stuff!

    Another consideration: What solution are you using???
    We have doctors who order 30 Units to 1 Liter fluid and those who only order 10 Units to a liter. Needless to say, a woman on 20 mU/min gets ALOT more fluid from the more dilute solution!

    Does this help???

    Haze
    Oh, man! Thanks so much for all that info!!! I never knew all that stuff about pit!! Nastola about the cow thing....eeeeeeeeeewwwwwwwwww. Makes me feel better that an 'old timer' has never seen water intox!!
  10. by   joyrochelle
    Originally posted by HazeK
    Again, cudos to Shay, who wrote:




    it often goes back to this question:

    DO YOU WANT TO BE A GOOD NURSE? OR A NICE NURSE?



    a good nurse would wait for the epidural until the Vertex is well positioned and -1 to 0 station....a nice nurse wants the patient to like her ....



    you can only pick one answer!! :-)
    of course yesterday at work i had a jack*ss of a dr., that wouldn't come into the hosptial for his patient to get an epidural, and mysteriously no one would cover his patient, so she went without a thing ( she was 5 when we called, and then when the house MD went to recheck her to see if she could take nubain she was 9) so she was my star of the week. and a prime....she was qa little pissed to say the least. but the house dr told her what was up, and i felt like a good nurse, cuz now that patient is no longer *that* dr's patient. i love working with go get `em residents like that....gets me all fired up and patient advocate-y!



    also about the h20 intox thing, it was somnething i had heard and wanted to start good habits now if it were true. we personally only put 10 units into a liter, but i think i have only seen it up to about 16 units total at it's highest.


    another question though here:: have you found that with GDM's that ANY tocolytic falesly raises BS? i know terb does, but what about indocin or mag??

    I had a MGS04 pt whose BS was a little elevated although NPO for the last 24 hrs. yet when I asked know it all nurse ( th eone mentioned before) she said NO waY! I know terb does and that's it! grrrrr. I can't wait until she leaves to have her baby, either that or i go to midnights! ( THAT'll keep me chuggin through at 3 am!!!)



    thnak dolls---joy
  11. by   mark_LD_RN
    pitocin water intoxication does happen have only seen in once so far for my self ,the pt was low dose pitted X2, then pitocin induction per active management protocol, ended up as a c/s due to FTP. Then recieved pit in recovery and post partum pt ended up with water intoxication. dr first diagnosis was CHF.
    the acynclitic thing i have seen mostly related to early epidurals, andd early AROM.
    i think your positioning of patients sounds fine, i use multiple positions depending on patients comfort ,pushing effectiveness, epidural or not, alot of thing to consider by try to find what works.

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