Cultural diversity help

[OBnurse3]

How does your facility handle those patients that refuse male physicians and there is no female physician on-call??? We are having a problem with this at our small-ish hospital, as we have only 2 female OB/GYNs on staff, one of which is on maternity leave. Looking for input to take to the managers' meeting, becuae we are DEFFINATELY not going to "just let the nurse deliver"as our patients' are suggesting!!!!! And HOW do you handle it when the request due to religious practice rather than personal preference???

Thank you in advance!!!

[bagladyrn, RN]

Who specifically says you "cannot"? I'm just wondering if that's simply one hospital or transport company's policy.

Because I'm here to tell you that we have.

I've worked at multiple hospitals (14 yrs traveling as well) and I have never seen a transport team willing to take a transport with a woman who is past 5 cm with actively changing cervix, active contractions who is possibly going to deliver in the transport. That is what I mean by active labor. Generally if it is an anticipated problem with the infant the transport is then changed to a neonatal transport team.

Also, how many all female transport teams do you know?

[rn/writer, RN]

Who says you can't transfer a woman in active labor after a certain point? It's federal law. EMTALA = the Federal Emergency Medical Treatment and Active Labor Act.

But the following quotes are taken from an EMTALA site:

Do all patients in active labor need to be admitted? It is common for patients to present with "false labor" or in the very early stages of true active labor, and certainly it is not necessary to admit all such patients.

Patients like this need not be admitted. They can have the situation (no female MD available) explained to them and they can make a choice. Such a patient doesn't have to be discharged because she was never admitted. As for transfer, I would think assistance could be provided, but whoever brought her in could take her wherever she wants to go. Hospital #1 might be able to help her determine an appropriate destination, but they are not obligated to provide care that she says she will ultimately refuse.

EMTALA clearly requires an examination ("medical screening examination") to determine the stage of labor, in order to make the determination of whether the patient has reached the level at which a safe transfer cannot be effectuated. If the patient is at the stage at which a safe transfer could be arranged, she can be discharged without a violation of EMTALA.

Again, just being in active labor is not the determining factor. If it appears that safe transfer can still be accomplished, said transfer can still occur.

This can be one of the most problematic areas of application of the language of EMTALA. Since a seemingly safe and normal course of labor can suddenly take a turn for the worse, it can often be very difficult to determine precisely where the line for "safe transfer" is crossed. As with the application of the other key language of the statute, the determination of where the line is located is ultimately a medical decision.

Here's the rub. It's a medical decision that should be determined by a medical examination. As a nurse, I would not want to be the one whose exam was the basis for calling the shots. It would appear that, legally speaking, a physician exam would be required. But if you have no female doc to do the exam, how can you meet this requirement. But if you have a female doc, then you don't have the problem in the first place.

I suppose it could be that you have a female doc available at the time or one can be called in for the exam, but if the birth doesn't occur for many hours, she may not be able to attend.

In addition to explaining that a female doc might not be available for the delivery, the forms people are signing during the pregnancy need to insist that, while all practical measures will be taken to accommodate their preference, in an emergent situation, they agree to receive care from either sex.

If this is not something they are willing to agree to, they should deliver elsewhere, and this should be scoped out early enough in the pregnancy to make other arrangements.

It cannot be that nurses and male docs have to stand by and watch a woman and/or her baby struggle and suffer and have their hands tied. That is just not right.

[Ruby Vee, BSN]

patients have the right to refuse being cared for by anyone they choose to refuse. in the case where it's a religious or cultural rule, they don't have the option of accepting who is available at your facility. it would make their stay and care stressful to them and maybe even be a sin or at least a big personal transgression. they have the right to refuse and your facility (not you) needs to find someone who fits what they need, or find another place they can be transferred to. patients come to a hospital assuming their needs will be met. it's not their fault they can't accept what's available, when it's a cultural or religious rule. since they are in our care, it's up to us to find what works for them in such situations.

while you're right that patients have the right to refuse being cared for by anyone they choose to refuse, i disagree with you that "they don't have the option of accepting who is available at your facility." they chose to be living in that area, an area in which they surely know theirs is not the predominate culture. surely it must have occurred to them before they're actually in labor that there may not be a female provider available. i doubt that there are female providers in some of the more oppressed societies where these persons originated. it is up to the person who has the cultural or religious restriction to ensure that their caregivers will be appropriate to their needs; not up to the facility to provide what is demanded by every cultural group who happens to live in the area.

[Ruby Vee, BSN]

right now, from what i see in the post, they are required to sign a paper saying they understand they might be delivered by a male and if they don't like it they need to find another doc. but what it looks like they are doing, however is signing it and then continuing to see the female provider throughout their pregnancy hoping to not have to deal with the issue. i guess the way i see it is if the male doc issue became an issue before it was close to delivery, then the patient might actually be forced to go to a different provider. so, make the patients see the male docs for prenatal care; rotate providers so the patients know you mean it.

this doesn't help the op with her dilemma, but it's an excellent idea nonetheless and ought to be passed on the the providers involved.