Augmenting Labor (particularly before 39 weeks)

Specialties Ob/Gyn

Published

We have had a couple of cases lately where there has been conflicting opinions regarding the plan of care for patients between 37+0 and 38+6 weeks who present with regular contractions and/or very slow cervical change. For example, a patient comes in at 2cm, contracting q5 minutes, but makes little change over the course of several hours. Some physicians would opt to start pitocin, as the patient was already contracting and making slow change. Others would refuse to start pitocin, citing the policy of no elective inductions prior to 39 weeks. How does your unit define augmentation vs induction? Does your hospital have a policy on labor augmentation? If so, is it determined by gestation, contraction pattern, cervical dilation, cervical change, induction agent, something else?

Specializes in Community, OB, Nursery.
I like the "6 is the new 4" motto that's going around. I've seen our triage turn away women who were 5cm, but only contracting mildly and irregularly and not making any change after several hours.

My friend who is a new CNM grad is famous when she's staffing in L&D (we have a few CNMs who work as labor nurses for whatever reason) for looking at the tree board (oops, tree = triage) and seeing anyone pop up, say 4/75/-2 and saying to herself, "Honey, you ain't in labor, go to the house!" Triple this if it's a G1.

Unless there's something problematic going on or unless they're being atypical primes and just rocking and rolling, I really don't understand why they keep 4cm primes.

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Specializes in hospice.
I really don't understand why they keep 4cm primes.

$$$$$$$$$$ The sooner they get them admitted, the sooner they can start billing, and of course you're not gonna sit there and do nothing, so they start meddling and piling up interventions they can bill for. L&D is the money maker, so milk it for all it's worth.

I was very happy to see posts from some nurses whose hospitals don't think that way, but I think we can probably all agree that it's still a problem many places.

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Specializes in Community, OB, Nursery.
$$$$$$$$$$ The sooner they get them admitted, the sooner they can start billing, and of course you're not gonna sit there and do nothing, so they start meddling and piling up interventions they can bill for. L&D is the money maker, so milk it for all it's worth.

I understand that bit of it. And the bit about some docs/MWs (note that I say some, I happen to work with some pretty darn good ones) not wanting to do the patient education bit about not really being in labor and what can happen if we start doing stuff to you when you're not really in labor.

What I don't understand is why it's acceptable to put that above what really is best practice in most cases. Urgh. Obviously we are in agreement here, LOL.

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Specializes in OB.
I like the "6 is the new 4" motto that's going around. I've seen our triage turn away women who were 5cm, but only contracting mildly and irregularly and not making any change after several hours.

Agreed. Forgot to mention in my prior post, that even if someone is 4 or 5 cms but I feel like they are not truly active, I will generally fudge the exam and say they're 3, if I feel like the attending I'm on with will want to keep them no matter what, just because they're 4 or more. It's the game we have to play, sometimes.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Hey, I was a 4cm prime who went from "in active labor" to "delivered" in under 4 hours.

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Specializes in Community, OB, Nursery.
Hey, I was a 4cm prime who went from "in active labor" to "delivered" in under 4 hours.

Lucky. You rocked and rolled.

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Specializes in MedSurg,Cardiac,Mental Health,Clinic.
At my facility a pt that us less than 39 weeks contracting Q5 and 2cm will be hydrated to see if the contractions subside. If no changes she will go home. On the flip side the same pt may be sent walking to see if she makes changes, if she does she comes in, if not home she goes. For a pt to be induced

Augmentation, the pt has been 5cm for some odd hours and her contractions went from Q2 to Q5-7.

Induction....we don't start with pitocin for induction.

I don't understand how some of these people deal with being sent home like that. I just had my fourth baby a few months ago and I was in labor. My labor started with a bang late at night and two hours later I was at the hospital because I was hurting so bad and afraid I might deliver quick. I was having severe back labor, shakes, nausea and vomiting, contractions every 5 minutes, and bloody show,but because I wasn't dilated yet they mentioned just sending me home. I was in so much agony and one of the nurses tried to tell me I was only dehydrated. It was my fourth baby so I knew I was in full blown labor. They were telling me I shouldn't be hurting so bad because I was soft but still high and closed. I was a mess and trying to figure out how I was going to make it through the pain and get back in the car and ride home like that. Thankfully the doctor on call told them to give me some Stadol IM and let me stay. Once they let me get out of the triage bed and let me walk between contractions I was dilated to 4 within 30 min to an hour. I had a 9 pound 15 oz posterior baby about 4 or 5 hours later. Dilation isn't the only sign of labor and not everyone's labor progresses the same. How do they just decide someone is not in labor and send people home in so much pain? I remember my back hurting so bad and when they said they might send me home I was so discouraged wondering how I was going to make it .

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Specializes in OB.
I don't understand how some of these people deal with being sent home like that. I just had my fourth baby a few months ago and I was in labor. My labor started with a bang late at night and two hours later I was at the hospital because I was hurting so bad and afraid I might deliver quick. I was having severe back labor, shakes, nausea and vomiting, contractions every 5 minutes, and bloody show,but because I wasn't dilated yet they mentioned just sending me home. I was in so much agony and one of the nurses tried to tell me I was only dehydrated. It was my fourth baby so I knew I was in full blown labor. They were telling me I shouldn't be hurting so bad because I was soft but still high and closed. I was a mess and trying to figure out how I was going to make it through the pain and get back in the car and ride home like that. Thankfully the doctor on call told them to give me some Stadol IM and let me stay. Once they let me get out of the triage bed and let me walk between contractions I was dilated to 4 within 30 min to an hour. I had a 9 pound 15 oz posterior baby about 4 or 5 hours later. Dilation isn't the only sign of labor and not everyone's labor progresses the same. How do they just decide someone is not in labor and send people home in so much pain? I remember my back hurting so bad and when they said they might send me home I was so discouraged wondering how I was going to make it .

From my perspective at least, I wouldn't have sent you home, I would have kept you and walked you. You were a multip, contracting every 5 minutes, vomiting, with some bloody show. That's a different picture. We "decide someone is in labor" based on a full clinical picture. Everyone's labor course will be different and we make our best judgement calls. This is part of my problem with hospital birth, trying to fit every woman's different experience into one little box. Congrats on your new baby, sounds like you did an amazing job despite a difficult set of circumstances!

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Specializes in Nurse-Midwife.
Dilation isn't the only sign of labor and not everyone's labor progresses the same.

This is absolutely true.

There are a lot of factors that come into play when figuring out if a patient is in labor or not - and the rules get slushy depending on if there's a unit teeming with patients or if there are plenty of rooms available. Doctors like to hear about cervical change - and if a patient is miserable - even without cervical change - we can find a way to get them admitted for labor. If a patient is open to going home - I will gently encourage it - because we will torture you and your baby to get it to come out. That's what we do. Patients don't get to hang out on the L&D unit in prodromal or latent labor. That's the way it is. Do I agree with this? No. Is this the culture where I work? Yes.

This is a question about policies/practices in our hospitals - how do we augment labor prior to 39 weeks.

I can't say it never happens - because it does. And I can't say that we never admit patients who aren't in labor - because we do. We get them into labor - (or we get them exhausted and/or infected) and we get those kiddos out. Not always the most pleasant (or healthiest!) experience all around. But it happens.

My opinion differs from common practice - but no one is asking my opinion, and I'm not in charge. If a patient is open to hearing about why it's not the best idea to be admitted to the hospital prior to being in labor, I will share that and let them make a decision. I also let them know if they get out into the parking lot and contractions ramp up 10 minutes after leaving - they can come back! We're open 24/7!

It's absolutely true that a woman's labor can go from 2cm to BABY OUT in not-very-many-minutes. A cervical exam is not the only assessment taken into account.

If a woman is texting, joking around, and watching TV for the 1-2 hours we're observing her for labor (particularly a first time mom), I'll suggest she come back when texting, laughing and joking aren't spontaneously happening any more.

Some of those patients come back laboring 6 hours later, but I would say the majority come back days or 1-2-3 weeks later.

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Specializes in L&D.
I don't understand how some of these people deal with being sent home like that. I just had my fourth baby a few months ago and I was in labor. My labor started with a bang late at night and two hours later I was at the hospital because I was hurting so bad and afraid I might deliver quick. I was having severe back labor, shakes, nausea and vomiting, contractions every 5 minutes, and bloody show,but because I wasn't dilated yet they mentioned just sending me home. I was in so much agony and one of the nurses tried to tell me I was only dehydrated. It was my fourth baby so I knew I was in full blown labor. They were telling me I shouldn't be hurting so bad because I was soft but still high and closed. I was a mess and trying to figure out how I was going to make it through the pain and get back in the car and ride home like that. Thankfully the doctor on call told them to give me some Stadol IM and let me stay. Once they let me get out of the triage bed and let me walk between contractions I was dilated to 4 within 30 min to an hour. I had a 9 pound 15 oz posterior baby about 4 or 5 hours later. Dilation isn't the only sign of labor and not everyone's labor progresses the same. How do they just decide someone is not in labor and send people home in so much pain? I remember my back hurting so bad and when they said they might send me home I was so discouraged wondering how I was going to make it .

Given all that you said they wouldn't have sent you home. You're a multi para exhibiting all the signs of labor. They wouldn't take the chance of sending you home and then hours or an hour later you deliver at home.

Some of the women they send home are dehydrated, others are in the latent phase. They may return in active labor a day or 2 later, not all some.

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