Evidence Based Care

[AspiringNurseMW]

Hello,

I am hoping to start my ADN program the summer of 2015. My long term goal is to eventually be a Midwife but I would love to work in L&D while I work on my BSN. I am a doula and starting training soon to be a Childbirth Educator.

My question is do you or how do you stand up to/ work with doctors that DO NOT provide evidence based care. Are they common, using fear tactics to push a c section, increasing pit unnecessarily, AROM, pushing an epidural on patients who do not want it, or possibly pit to distress (does that even happen?). Especially in the context of patients who actually care about these things.

Or do you for the most part work pretty independently and are able to skirt around orders that go against patients wishes or are not evidence based.

I want to eventually work in a more naturally minded environment, whether this means birth center or homebirth but if I do have the privilege of working in L&D I do not want to get overwhelmed by the medicalized view on birth. Does this post make sense?

[klone, MSN, RN]

I've never been in a situation where a provider pushed an epidural on a patient. It's been my experience that since the provider is not at the bedside helping the patient through the contractions, they really couldn't care less what the patient's pain management plan is.

As far as pushing other interventions that patients don't want, I make it very clear to patients that they cannot be forced into doing anything they don't want, and they have the right to refuse any interventions.

And I've had situations where the provider has called in at 2 am to check on the status of a patient, and they would ask what the Pit was at, and when I'd tell them it's at 4 or 5, and they'd mentally calculate in their head what it could be at in the elapsed time (for example, 2 mu q 20 minutes means that it should be at at least 20 by that time), and they'd get ****** off that it wasn't higher, and you just have to be ready to defend your actions ("she's contracting every 3 minutes and is making steady change, and she wants to do this without pain medication").

Sometimes it's a challenge, but mostly it's not. There is a definite niche for nurses who are natural minded and want to help women who want to have a natural childbirth and use non-pharmaceutical pain management. In my experience, that type of birth is a lot more work for the nurse, so for the nurses who WANT to be assigned to those types of patients, the charge nurse is grateful to have you.

[cayenne06, MSN, CNM]

I am a CPM, an LDRP RN and a student CNM. My LDRP job is at a small community hospital. Cords are cut immediately, before baby is handed to mom. Bulb suction is done routinely. Babies are never kept skin to skin with mom for more than a few minutes, if at all. C sections are called for FTP well before all interventions have been used. Social inductions are almost more common that spontaneous labors. We give out formula samples like candy.

It's very difficult. I don't have any good answers for you. I provide the best, evidence based care I can and make sure I provide accurate information to patients. I much prefer being an OB provider to being an OB RN.

[queenanneslace, ADN, MSN, APRN, CNM]

Are they common, using fear tactics to push a c section,

YES

increasing pit unnecessarily,

YES

AROM

YES

pushing an epidural on patients who do not want it,

NO: most women want epidurals.

or possibly pit to distress (does that even happen?)

YES, this happens.

Sigh - how do you stand up to this? Sometimes you don't. Sometimes you just do what they say and chart that they told you to do it. Sometimes you provide evidence for doing things the way you're doing them "The patient is contracting q 2-3 minutes, to increase the rate of oxytocin may cause tachysystole." Sometimes the mother has a strong opinion about interventions, and you act as her advocate - most physicians understand the concept of consent - and most respect a patient's wishes - if patients have explicit wishes. Many patients do not have explicit wishes.

Many patients want to come to the hospital, "get my epidural" and have the nurse and the doctors do something to make their babies come out.

This is not the mentality of women who want natural birth - and who chose to give birth in out-of-hospital settings. My background is in OOH settings. And now I'm working in a L&D unit that has some REALLY backwards standard birthing practices. There are some lines I won't cross. I won't increase oxytocin on a crappy looking strip. I follow safety protocols and guidelines. I practice safe medication administration. There are corners I won't cut. But when a doctor orders me to increase the Pitocin because they've been poised at the perineum for 90 seconds and are sick of waiting, I just turn it up. Arguing in front of the patient seems incredibly unprofessional in that situation... and the doc is in the room so if heart tones go south, then they'll be notified when I'm notified.

Sigh. I have no answers. If you want to learn about natural birth, you'll need to learn about it in an environment where it is supported - that is usually in an OOH setting with midwives.

[Elvish, BSN, DNP, RN, NP]

This is where you will have to be really discriminating in where you choose to work. (Easier said than done, I know.) Wherever you end up, your main job will be 'patient advocate'.

I am really blessed to work at a progressive place with one of the lowest c-section rates (

About the only thing I see on your list that's pretty routine where I am is AROM, although if mom is in a good labor pattern they are hands-off on that as well. A lot of AROM that I see is when she gets to the hospital with at a rim and the only thing keeping her from delivering is the bulging bag. In that case I don't personally hold it against the doc for breaking her water, although there are worse things than being born en caul. :)

Best wishes to you in your career.