TDAP Immunization

mAGGI315 · May 25, 2010

Pro vaccine isn't the issue I'm talking about. I'm talking about common sense vaccinations. The question to ask is not "can this save 30 babies lives per year?", but rather "can this kill more than 30 mothers per year?" or "how many infections will this hide and potentially increase health care costs, cause lost uteruses, etc?".

Informed consent is not legal under narcotics. That's just the way it is, and in a lawsuit it looks bad. Doing it as they walk out the door might protect you there, but it sets them up even further for an infection when they get home and have infection symptoms and don't them treated right away.

The question should be "has this been studied throroughly and thought out or is a reaction?" That's not good science, not good nurse, not evidence based practice.

I do care about babies getting sick. But I care about sick mom's, moms who might lose a uterus (which we did have one this past year) and moms who might die.

I think we're in uncharted territory, not practicing evidence based nursing practice, but rather going on a reaction of what might happen case scenario, which is fear based. We don't even have consents signed in our area hospitals, which further ups the risks. I would hope that nursing would be improving by now in these areas, but we're still reacting,instead of being ahead of the game.

In another few years when the numbers come out and we see the harmed mothers and the effects, we might rethink this policy, just like we do every 5-10 years, too late for them, and shame on us for poor science and poor research (and picking and choosing recommendations in this case instead of either enforcing all of them or none of them).

This is one area I illustrate to my students how we left common sense at the door and all lined up without thinking it through. I want my students to think, to practice evidence-based nursing, to question, and especially to not react with fear, but with reason.

dscrn · May 25, 2010

My daughter is one who gets "reactions" to Tdap imunizations-been told that she is reacting to the adjudant. She developes sterile abcesses-resulted in hospitalization when she was 2, outpt abcess I and D when she was 12, following a dog bite. Very uncomfortable, but I still feel that the immunizations outweigh the disease..

klone, MSN, RN · May 26, 2010

I hear what you're saying Maggi, but I guess I just don't agree. A doctor who would perform a hysterectomy on a woman because she has a fever of "unknown idiology" that was caused by a vaccine is one stupid doctor. A lot more goes into diagnosing chorio than just "huh, she has a lowgrade fever. Guess we should take out her girlie parts."

How do you know we're not practicing evidence-based nursing practice by providing the TDaP to postpartum women? Is there research?

And just so you know where I'm coming from, I'm not pro-vax. None of my children are vaccinated (although my son, 12, is due to get some vaxes that I think are important to protect him as an adolescent/future sexually active person). I'm just not convinced that offering the TDaP to postpartum women in order to protect their newborns is of the debil.

klone, MSN, RN · May 26, 2010

Also wanted to mention, at not every point during a woman's stay in OB is she under the influence of narcotics. Of course I wouldn't ask for an epidural consent to be signed right after giving her a dose of Nubain, but at not every point during her stay is she high on narcotics. There is plenty of opportunity to obtain informed consent, and like the myriad other bits of info we provide to parents during their stay the VIS is something for them to have and read when they have the opportunity. My legal obligation is to provide it to them, not sit down and read it to them or make sure they've read it front and back before giving consent.

mAGGI315 · May 26, 2010

NO,you're missing the point..these women do sometimes have infection, however, the s/s are the same as the vaccines, so the women read the s/s, think that's the problem and don't call or come in...when it finally gets bad and they do come in, it's so far gone, they end up losing their uterus or worse, their lives. The vaccines and their side effects mask the infections and they aren't caught in time.

As a lactation consultant, I see that frequently too. Moms are sore from the tetorifice portion, especially their arms and can't nurse properly. They become engorged, and end up with blocked ducts and mastitis.

It's great you want to protect 30 babies per year. And there's tons of ways to do that. but what about protecting the moms? There's lots more that suffer complications from these shots given during this time,they are forgotten or tossed to the side. Are the babies more important than the moms?

I do know how horrible pertussis is. My children and I have had pertussis and yes it is horrible. My grandmothers sister died from it.

Is this evidence based? No, I can tell you it's not. Do a literature review, i have for a class. And for my students, it's not. So, I can speak and say it's fear based, not evidence based. Evidence base would look at the statistics, how many babies are born in the US, then divide that number by 30. Then look at how many women have had infections that are hidden by the s/s after receiving the immunizations, have had problems with breastfeeding and quit (and there is percentage out there that have quit and having the shot and being sore and sick feel has contributed to it), and take all those numbers to see which is of the great risk and greater benefits.

I think you're thinking we're saying that doctors are operating because they see a fever from the vaccine and think it's an infection. It's the opposite. And it's dangerous. And unethical.

Plenty of time to obtain informed consent? Do you work in ob? Because those of us that do would disagee with that. Some women get discharged in 24 hours, are tired and haven't slept, deliver a baby, sleep, wake up with a room full of visitors, start popping the pain killers right up til they walk out the door! I chuckle when my students get a taste of what a busy ob floor can feel like after a couple of days, especially with a few episodes of drama thrown in for good taste. Maybe you're floor is different, but for a test, give them the VIS and informed consent, leave, come back and ask if they can spit the info back to you before you give the shot. That way you'll know if true informed consent has taken place. Do a literature search on "informed consent definition" and you'll see that the definition is whether the patient understands and can repeat back the information. I have my students do this and they are surprised to see the patients have no clue what shot they are getting, what's it's for, what the side effects will be, or most anything else we just told them...

My legal obligation is not my greatest concern, it's my ethical obligation. My patient advocacy concern. And that is to BOTH my patients, mom and baby. It's a different world in ob when you have two patients who equally need protected and cared for. If nurses are only worried about the legalism, then they are in the wrong field, I would take a student to task for that attitude. I want a nurse who is looking out for MY best interest, no matter what.

Again, it's about whether it's an appropriate time. Whether statistically we're making a difference or making things worse. Time will tell, I know we've started to keep track and probably will start reporting these infections, I know insurance companies are NOT happy and may end up not paying for them, just like they don't pay for cath related UTI's.

klone, MSN, RN · May 26, 2010

NO,you're missing the point..these women do sometimes have infection, however, the s/s are the same as the vaccines, so the women read the s/s, think that's the problem and don't call or come in...when it finally gets bad and they do come in, it's so far gone, they end up losing their uterus or worse, their lives. The vaccines and their side effects mask the infections and they aren't caught in time.

Well, then their discharge nurses aren't doing their jobs. We tell them any time they develop a fever of 100F or greater, they should immediately call their doctor. It's up to the doctor to determine if their fever is caused by a vaccine (which generally only causes low-grade fevers) or something more serious.

redbeads · May 26, 2010

Yep, at my last facility, when we'd have to give the rubella vaccine, we would do it last thing, practically just as she was walking out the door.

I believe a reason for giving the rubella vaccine right before the mom leaves the hospital is b/c it has a small amount of live virus in it....so this decreases exposure for others in the hospital.

redbeads · May 26, 2010

klone, MSN, RN · May 26, 2010

I believe the reason for giving the rubella vaccine right before the mom leaves the hospital is b/c it has a small amount of live virus in it....so this decreases exposure for others in the hospital.

No, the reason why we waited until right before leaving before giving it was because we knew that a normal side effect is a low-grade temperature, and we didn't want that to cause the mom to have to stay and undergo lots of unnecessary bloodwork.

redbeads · May 26, 2010

No, the reason why we waited until right before leaving before giving it was because we knew that a normal side effect is a low-grade temperature, and we didn't want that to cause the mom to have to stay and undergo lots of unnecessary bloodwork.

Good to know...point taken

Elvish, BSN, DNP, RN, NP · May 26, 2010

We sometimes like to defer MMR being given until day of discharge as well, but there are people who work days who don't like that extra thing to do in the rush of discharges. (which I can understand, but since 98% (give or take) of women are rubella immune, how often do we really have to give it?)

mAGGI315 · May 26, 2010

That is a problem, if we give it in the hospital with the fevers, but when we rush them out the door, what to do when they get a fever? If they are taking ibuprofen, like many are and still get a low grade and call dr., then it puts the dr. (or in my case, the midwife) in a bad position. If I say it's nothing to worry about and I'm wrong, I'm at fault. On the other hand, running every mom in for visual inspection is another added burden to these new, overwhelmed moms.

Here's one study that shows a little about PP infections, these moms did not get the shots, but illustrates the dilemma we are causing for ourselves. There's also the dilemma that a study of 12k women, about 1-2% developed pneumonia, appendicitis and another common infection up to a few weeks after giving birth, so the conclusion was having a baby increased these things (which I have seen, especially appendicitis). So, again, we run the risk of masking it.

Nearly all postpartum infections became manifest after hospital discharge (94%). Furthermore, most (74%) of these postdischarge infections were diagnosed and treated entirely in the ambulatory setting without the patients' returning to the hospital where they delivered for evaluation or treatment, emphasizing the need for postdischarge surveillance methods that are not dependent on hospital-based data.

This research was supported by the Harvard Pilgrim Health Care Foundation and the Eastern Massachusetts-Centers for Disease Control and Prevention Epicenter (UR8/CCU115079).

If we were having home nursing visits like we did years ago, I might not be so concerned, but I can't even get the insurance companies to pay for lactation visits. This study showed how most were treated without readmission, we are definitely seeing more readmitted these days with more serious infections and more serious outcomes. I admit, lots of factors, but we should be looking at each contributing one.

Elvish:

We accidentally gave the Rubella to a woman who was immune last semester and our college was written up by the hospital's risk management team, is that not the same at your facility? We now have to actually look up the labs themselves, because all women on the unit have standing orders for MMR and Adacel. Don't get me started on giving both on the day of discharge! The doctors aren't taking into effect other smallchildren in the home, allergies (my daughter who is 20 was just assured of the safety of getting these two for her CNA job even though she's horribly allergic to eggs, sigh, thank goodness for epi pens, I went back to the office with her to let the nurses see what they had done), people on chemo, etc.

And I really don't see the nurses going through these checklists with the patients to make sure it's OK, they just hand them the VIS, and then give them the shot. Scary! When patients are afraid to have a student, I tell them they should be happy, we triple check everything!