Would I be considered a "difficult patient?"

NICU_Nurse, BSN, RN · Aug 31, 2003

I'm just curious- why would you refuse the HepB shot, Vitamin K, and eye ointment?

The Vitamin K is VERY important in newborns! Infants are born without the normal clotting mechanisms that are present later in life, and are at risk up to the first 6 months or so for VKDB (defeciency bleeding). K doesn't cross the placental membrane well at all, and is not transmitted well via breastmilk after birth (prepared formulas are required by law to include VK).

Hepatitis B transmission is extremely high in infants, regardless of the lack of presence of the disease within the family (Only about 1 in 4 infants with documented HepB had a family member with HepB). Not to mention, the vaccine is much more effective when given early vs. given late, which is why it's included in routine newborn vaccinations, rather than suggested to be given later in life (this benefit starts to decrease at about 2 months of life). There is no cure for HepB, and children who contract it experience symptoms and effects of the disease much greater than adults, who may go years with no clue that they have it and with few to no disease-related effects. It is unlikely that you could prevent HepB transmission in your child without the vaccination- there are simply too many factors at play for you to control all of them. No one ASKS for their children to be infected, it just "happens". Not to mention that this vaccine will protect your child when they are of adolescent age, when they are much more likely to engage in behaviors or have intimate contact with people who might put them at risk for contracting the disease. I guess I'm having difficulty understanding why this would be unappealing to you...?

As far as the erythromycin, this I understand (sort of) why you would pass on. Sort of. :) If you are not infected with gonococcal disease or chlamydia , you might assume that you have no risk of passing this to your child, which would be correct. However, women frequently have NO SYMPTOMS of GD *or* Chlamydia and before you pass on the ointment, I would make absolutely sure that you and your husband have been tested for this and cleared by your personal physician/OB-GYN. Chlamydia can exist in your urethra OR your cervix without showing any symptoms at all. You can be tested by your doctor, but please realize that these tests are only about 60% (Gonorrhea) and 80-90% (Chlamydia) effective, and you could be pronounced falsely negative or positive by your MD. Because this intervention at birth is painless, I am, again, not understanding why you would be opposed to it. Conjunctivitis caused by other bacteria may be prevented by erythromycin application as well (though I can't quote any to you off the top of my head!).

With the erythromicin, I have heard of natural alternatives, but I have NO IDEA how safe or effective they are- use of breastmilk or echinacea, but before you insist upon this, I would caution you STRONGLY to investigate this further for actual medical/scientific research from a valid source.

Otherwise, and I'm no L&D nurse, the majority of your plan sounds reasonable to me. It seems like you want to really make the most of your homebirth, and I applaud you for that.

Edited to add: Good for you with the raspberry and nettle teas! I'm a proponent of both during pregnancy unless they're contraindicated for some reason (get that folic acid in ya'!).

SmilingBluEyes · Aug 31, 2003

These sound like reasonable requests to me. I would NOT label you as "difficult" at all. But I would ask YOU keep an open mind, as you expect staff members to do, in considering the importance of your birth plans and personal values. Cooperation works best when it is two-way.

As for me as an RN, I would respect these requests to my utmost, but a doctor/midwife (in certain institutions), may nix some of them. It would always be a good idea to discuss these requests/ideals with your obstetric health care provider or midwife WELL in advance of labor and delivery to work it all out and so there are no surprises or denials of your requests based on lack of advance preparation.

May I ask WHY you are asking this, since you stated you do not intend to give birth in a hospital again? Just curious...Hope this helped.

fergus51 · Aug 31, 2003

I think you would be labelled difficult if you came in with the attitude that all that was written in stone and unchangeable. If you are willing for some give and take, depending on how things go you wouldn't be labelled difficult.

For instance, we only use doppler intermittent monitoring on healthy women (4 times in an hour through a contraction and for one minute after). If you didn't let me do this, I would be very concerned. If there was a decel or something up and you didn't let me put you on the continuous EFM, I would think you were difficult. If things sounded good and we kept going with intermittent, I wouldn't have any problem. If Your water broke and there was a reason I suspected a cord prolapse and you refused a vag exam, I would label you difficult. I think my point is I don't like to do any unecessary interventions and understand why a woman wouldn't want those as a part of her birth either, but when things go wrong I need to do those interventions for your safety and the safety of your baby. Birth is natural, but it isn't without risks.

As an aside, I love people who know what they want with their births, it shows they have put a lot of thought into it. I think a lot of it comes from the wording and the tone of the plan. The way you've worded everything (I won't, I'll refuse, etc) sounds a bit adversarial. I would simply say "I would like to push only when I feel the urge" "I want to push in the positions I am comfortable in" "I would like a Heplock to give me more freedom of movement" (I have never expected a patient to ask me before moving anyways), etc.

fergus51 · Aug 31, 2003

I forgot to say, a lot of this would be the job of the physician. You would talk to them about not wanting pitocin and erythro, vit k, etc before coming to the hospital. It isn't my job to decide who gets what meds.

renerian, BSN, RN · Aug 31, 2003

I know I am glad I had the monitoring as it detected fetal distress in my first child.

Some things I would say fine, some not. I try not to label anyone.

renerian

skdauriaRNC · Aug 31, 2003

Sorry, I'd call you difficult. But I respect your forethought and the obvious way this experience and your baby will mean a great deal to you. I urge you to rethink a few of the issues as pointed out by nicu nurse. Good luck.

keeper · Aug 31, 2003

Thanks so much for all the replies. First, I wanted to reiterate that in the event of complications....decels, prolapse, fever, etc, I am always willing to throw my birthplan right out the window. I'm just not going to concede if it's only a matter of hospital policy. I will refuse if I think that is the only reason an intervention is being pursued. In the two hospital births that I did have, I was careful to choose a doctor with the same views and with an open mind. (He happily considered a lot of my birth an "experiment.")

I'm not pregnant at this point and don't plan to be for at least another year, and yes, it is a strange question, since I don't plan a hospital birth. I do hope to someday become a doula, and anticipate many of my clients will have the same kinds of requests and concerns. I wanted to guage what the feeling would be.

Many of you are in much more progressive hospitals than mine, so I'm glad to see what you are willing to allow. In mine, depending on the nurse, I WOULD have to loudly refuse many routine interventions to the point of signing waivers. I was considered a difficult patient simply because I had a birth plan, and it was nowhere near as militant as my post!

As for the newborn procedures, I have done a lot of research and just feel this is how I need things to be. I do get the hepB vaccine within two months, but I just don't feel we need to hurt a newborn that quickly after birth when waiting a week or so is reasonable. I do appreciate the info and advice.

For the record, I'm a pretty passionate person, and I have no problem being labeled as difficult. I have hopes that when I am a doula, my clients' rights of refusal will be respected, and I have even higher hopes that they will have to use them less and less as time passes.

Thanks again,

Sarah

fergus51 · Aug 31, 2003

I definintely agree Sarah that there are a lot of hospitals that have a long way to go in making themselves welcoming as well as safe. I do think some women labelled difficult are just very poor communicators. Women who come in with respectful birth plans as rough guides are fine. I say respectful because I have seen some that were downright insulting to me as a nurse.

I have looked after some patients I would describe as militant and in my experience they were just plain misinformed about most issues and came to the experience with a very confrontational attitude towards the staff, which only makes things worse. One didn't want any monitoring or interventions.... to people like that I would say "then stay home!". Aside from my concern for her safety, I had a lot of concern about my own liability.... I had another one who didn't want the cord cut until it stopped pulsating (which I can go along with), but the baby had a nuchal cord that had to be cut. She started YELLING when the baby went to the pediatrician first to be checked over. Those are the type of people I label as difficult!

kids · Aug 31, 2003

Originally posted by keeper
...I would...choose to complete the pku at a health dept, rather than the hospital...

I am not sure if this is possible, as there are specific time frames for the test(s) to be done.

In most States the testing is manditory and while the test is refered to as being the "PKU" the actual name is newborn screening. There are several metabolic disorders screened for using the blotter samples including congenital hypothyroidism. It would take me a bit to dig it up the reference but not long ago I read that informed consent is not required for the testing.

That said, I am not and never have been a L&D nurse, however I am a proponent of minimal interventions and come from a family with a active preference for home births. The majority of my nursing career has been spent caring for "medically fragile" children, a not insignificant number of the kids I have seen are living with the effects/consequences of metabolic disorders, some diagnosed too late to prevent brain damage.

keeper · Aug 31, 2003

kids r fun, the specific time frame in my state for the first test to be done is at 48 hours of age, and not before. Since I leave the hospital well before that time frame, it makes more sense to go to my local health department.

When I had my third child, I drove back an hour and a half to the hospital in the town I had lived previously, because I wanted to stay with the same doctor. (Moved halfway through the pregnancy). As per my birthplan, I was discharged 12 hours after the birth, but told by the hospital staff that I was required by law to return there for the pku. I told them I preferred to have it done at my local health department, which was ten minutes from my home, rather than drive back an hour and a half. They again told me I would be breaking the law if I did not return and do it there. As I was going through the paperwork, I found the waiver which would have allowed me to sign away their liability, but the nurse took it from me and again told me I had to return under penalty of law.

I did return, driving an hour and a half with three kids and my sister. The hospital charged my insurance (and me, with the coinsurance) $179 for a test that would have cost me $5 at the health department. I spoke with the nurse at the health department about this and she called the hospital and did some major chewing out.

The "rest of the story" is that the nurse who performed the pku at the hospital messed it up, and I had to go to the health department and have it redone anyway!

Sarah

fergus51 · Aug 31, 2003

Some people are just stupid. As long as it is done, who cares where?! A lot of our moms are discharged early and get the PKU done by their doc or PH nurse.