L&D - advocating for patients

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    Question for L&D nurses... Do you see a trend in your facility to pressure laboring women into inducing/augmenting labor (eg, with pit) when the situation may not merit this recommendation? If so, what types of explanations/reasons are typically presented to these patients - pseudomedical "risk reduction" reasons, reducing the patient's experience of discomfort (shortening labor), etc. Do you run into scenarios where a woman values taking a more natural approach but is worried after hearing a pseudomedical argument in favor for induction/augmentation - worried that a natural approach would place the baby or herself at risk? I'm curious how you identify these situations and if you have found any ways to advocate for the patient when you think the MD has inappropriate reasons for wanting to induce/augment.
    Last edit by AJPV on Jul 22, '11
    lindarn likes this.
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  3. 16 Comments so far...

  4. 0
    ooh no experience here but can't wait to see some of the responses...
  5. 1
    That is one reason I stay far away from L&D.
    Drugs for pain control are embraced in SICU, natural is not always considered a good thing, and differing political agendas/worldviews are less of an issue.
    I'm curious to hear responses too.
    lindarn likes this.
  6. 0
    Moved to L&D forum.
  7. 0
    Moved to OB/GYN forum.
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    Yes we see this a lot.
    Some patients don't care at all, other ask questions and request more time.
    Doctors give explanations like "Your contractions have spaced out/don't seem strong enough/you're still 3cm/4cm/5cm" I'd like to start some pitocin because we don't like labor to go on too long once your water's broken (even if they're the ones who broke the water!!!!) Most patients (unless they're committed to natural) do want a shorter labor so they agree.
    Patients who want natural are harder for the OBs to convince, but they usually do. Especially if they break down and get an epidural.
    Once you get an epidural you're sort of at their mercy.
    If you come in contracting every 10 min at 2cm and demand an epidural they will DEFINITELY pit you.
    It's frustrating. We can try and advocate, but we never win, so it just seems like a waste of energy to care.
    One thing I try and do is if they suggest augmenting with pit just based on contraction pattern, I urge them to check her and see if she's made change. Sometimes they're fully from contractions that were 4-5 minutes apart. So in that case, who cares how far about they are?!

    Once patients arrive in L&D for induction it's too late to do anything about that, though it's interesting and frustrating to hear the stupid explanations "My doctor thought because my due date is tomorrow and the baby seems big, that I should be induced today..." They just don't get it.

    The only time we can intervene there is if we're in triage. I saw one triage nurse advocate for that. The pt came in (rule out rupture, which was ruled out) and not really in labor. The OB said "Let's just keep her" meaning "induce her" b/c she was 40 weeks. But the pt wanted to go home! The nurse pointed this out. The OB acted all huffy about it, but finally agreed to let her go.

    What annoys me more than pit is probably AROM. Once they break the water they're on a clock. So AROM too early can lead to a c/s for infection or failure to progress. I've also seen AROM twice directly leading to emergency c/s from occult prolapsed cord.
    Once I had a patient preterm (Maybe 34 or 35 weeks...) In early preterm labor. She was dilating, but still early. After 34 weeks we don't stop preterm labor, but we also shouldn't be helping her along. The OB came BROKE HER WATER and the PITTED her. I wanted to vomit. I tried to fight it - charge nurse, manager, chief resident. But they said that although he shouldn't have broken her water, now that she's ruptured, she's committed to delivery, so start the pit.
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    adpiRN - thanks for your thoughts! In your experience, does initiating an epidural usually slow down labor to the point where pit is usually necessary?

    I think this shows why it is SO important for patients to seek out at least some basic science-based medical knowledge so they're prepared to make intelligent choices.
    DizzyLizzyNurse and lindarn like this.
  10. 1
    Quote from AJPV
    I think this shows why it is SO important for patients to seek out at least some basic science-based medical knowledge so they're prepared to make intelligent choices.
    I think this has two sides, though. If they were going through medical journals (reputable ones) - sure. But for a lot of laypeople, "basic science knowledge" comes from Dr. Google and is the bane of so many healthcare providers when patients get stuck with "whatever Google said".

    Tbh, I can't totally blame doctors. They know that /one/ case where /something/ goes wrong and they could have done something but elected to go au natural or whatever and the baby dies/is maimed/whatever, it's their butt slammed with a lawsuit before they can blink. Go America.
    DizzyLizzyNurse likes this.
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    nohika - I agree. It's important that we teach our patients where they can find sound medical info (not "Dr. Oprah"). But I guess what I'm saying is that if a woman is having an effectual progressing labor pattern, reassuring fetal heart rate tracings (no late or excessive variable decels), she's not post-term, no PROM, no evidence of chorio, no Rh-isoimmunization, no pregnancy-induced HTN, etc., I think she should question an MD's advice to AROM or to induce/augment. That MD should not be offended when asked to provide real reasons that are acceptable according to standards of practice.
  12. 0
    Quote from AJPV
    adpiRN - thanks for your thoughts! In your experience, does initiating an epidural usually slow down labor to the point where pit is usually necessary?

    I think this shows why it is SO important for patients to seek out at least some basic science-based medical knowledge so they're prepared to make intelligent choices.
    I haven't done my OB rotation yet, but is there a reason to NOT give pitocin once you have an epidural. The biggest mistake I eve made was letting the doctor start pitocin. I wanted to try and go natural, but after 7 hours on a pitocin drip I gave up and got the epidural. After that they were able to give me a lot more and I delivered less than 30 minutes after the epidural (went from 4cm to 10 in that time). I thought that the discomfort was the main deterrent from starting the pit, is it also harmful to mother or baby?


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