when to call for delivery, active management & patience

[ischialspines]

So this is really a bunch of random stuff related to policies and procedures and patients and adjusting to the 'hospital way' of L&D (physiological/expectant mgmt vs active mgmt). But I didn't want to make a bunch of separate posts. Bear with me.

1. When do you call the docs in? They are pretty forgiving with me as a new nurse but tend to be really grumpy when they are in the room longer than a couple of minutes before the birth. But they're grumpy if they miss it, too. It's really difficult to get that timing just right, and, as it is, if they're in they're there too long, mama might get an epis. I have no problem catching a baby without a doc (I trained as a homebirth midwife) but do have a problem with the paperwork involved. And, I'm glad they're there when I need them, i.e., for anything that involves cutting or sewing :)

2. While I love a lot of our docs at our hospital, I wonder if they could ever labor a patient? Would they even know how? They are there for so little of the labor, really. When they do come in, they like to meddle. Let me labor my mama! She doesn't need pit yet! Let her be! Do you have this problem? How do you keep the docs at bay?

3. I really do think many of our docs are very open and progressive. Still I've yet to see a birth without mama's legs in stirrups. I can push them in every which way imaginable (and I do), but no matter what, even if I might suggest otherwise, the stirrups come out and the legs go in them. I admit they're nice to rest legs on with an epidural, and most of my patients don't care too horribly much either way- in fact, they just expect that's how it's going to be- but it just seems kind of degrading for my mamas to be all splayed out like that. But maybe that's just my own biases and not so much a big deal? Do you see births in your hospital, with docs, without stirrups?

4. Don't get me started on the betadine prep for delivery (they know a lady parts's not sterile, right?). This isn't really a big deal, but just seems like an entirely necessary step. I can't imagine that it would help much with decontamination even if we were going to do an epis or need sutures. lady partss + gravity = there's going to be bacteria around.

5. Any docs that do delayed cord clamping, or even just patiently wait a minute or two for the placenta to be born (kind of related, right?)? I very rarely have seen a placenta be born by maternal effort in the hospital. Pretty much universal active management.

6. Prophylactic pitocin before/after placenta delivery (there are some docs that like it before and some like it after, but it goes through on everyone). Ours is 30 units, and then we usually hang another bag of 30 units, which means 60 units of pit on everyone post-delivery. I'm all for proph pit when there's any risk factors at all, but this seems excessive... what is your policy? I'd never felt such firmed-up uteri before :)

I know there's other stuff I've been wondering about, but this will do for now.

[ischialspines]

oh yes, and, related to #1 - I really wish docs had different days for seeing pts in clinic than being on call. That would make things easier.

[L&DRNJenn]

I'm interested to see your answers.

I agree with #1, it is very hard to predict and time just right. But it is there job to be there. I worked nights. Sounds like you work days, which be a little more difficult to coordinate.

I think #4 isn't a bad idea, especially when there is already a mess involved.

#6 is so very routine at where I worked. Unless it was a natural with out an IV running. They will get Pit IM and then we would notify the provider if we felt they needed IV pit during recovery.

[snazzy-jazzy, BSN, RN]

I train in Australia and it is completely different here. Unless there are or have been previous complications then the mother can decide on active management or physiological and even if she chooses active management we usually do delayed cord clamping so bub gets all that extra blood. Unless ofcourse there are complications which are not seen with every birth.

10 units of synto (your pit) given as an IM injection, used to be as the shoulders birthed for active management now we wait until baby is skin to skin (if everything is ok). Cannulas are only given if there have been previous issues. Stirrips not needed to be used very often at all, certainly not with every birth and I've only seen them used a few times , especially if the mum needed stitching afterwards. Midwives catch the babies, and are very protective of the mums peri. OBs do forceps, vacs, or in private hospitals. Betadine not used on the lady parts for birth.

[beachyfe]

1. when do you call the docs in? tend to be really grumpy when they are in the room longer than a couple of minutes before the birth. but they're grumpy if they miss it, too.

yeh, that's one of the hardest things to learn to do as an l&d nurse - be sure the doc doesn't arrive too early or too late. sure would be nice if they gave us a crystal ball during orientation! i eventually learned to sense when it was the "right" time to get the doc in. i always asked them how much notice they would need and how long would it take to arrive. at least they knew i was trying to help them.

2. while i love a lot of our docs at our hospital, i wonder if they could ever labor a patient? would they even know how? they are there for so little of the labor, really.

they are not trained or educated in conducting the labor - they depend on you to do that. frankly, i liked it that way. i also have experience in both homebirths and hospital births, so i am comfortable supporting the patient with whatever type of birth she wants within the bounds of safety.

3. i really do think many of our docs are very open and progressive. still i've yet to see a birth without mama's legs in stirrups.

while we did the majority of births in stirrups (mainly 'cuz most moms had epidurals), i had many moms who just pulled their legs back. a few docs would arrive for delivery and request the stirrups be put up, but at least the mom knew it was the doc asking and not me requiring them. i did whatever the patient or doc wanted. some docs would let us keep the bed together and they would just sit on the side.

4. don't get me started on the betadine prep for delivery (they know a lady parts's not sterile, right?).

yeh, it's a rather silly tradition. we always kidded with the mom that her baby was getting the "baptism by betadine." i think it's outdated, but some docs would sit there and not touch the mom until you got that betadine applied. oh well.

5. any docs that do delayed cord clamping, or even just patiently wait a minute or two for the placenta to be born (kind of related, right?)?

most of our docs would delay cord clamping if the parents asked, but not if they didn't. nearly all of them waited patiently for the placenta to be delivered spontaneously, though. i did see some nasty consequences for the ones who liked to "tug" on the cord - like the time the cord popped off before the placenta had detached!! i think that was a resident.

6. prophylactic pitocin before/after placenta delivery (there are some docs that like it before and some like it after, but it goes through on everyone).

that was pretty routine in my hospital. we gave one bag of pit wide open after delivery.