Delivering fetal demises

[sharonx]

Our anesthesiologists are refusing to do epidurals on mothers delivering a stillborn. They think that other meds are appropriate and enough because at this point we don't have to worry about harm to the baby. We think pain management would be so much better with an epidural. We cannot seem to find any research on this topic. I cannot believe that this is standard procedure. What is everyone else out there doing for these patients and if anyone has research articles, that would be so helpful to defend our case for these moms.

[SHGR, MSN, RN, CNS]

That is such an odd rationale. It would at least make logical sense if stronger meds were given to moms who had had fetal demise (like category X even) that you could not give to a mom with a live baby. There is enough pain in these cases already

As far as EBP goes, if you can't find highest level of evidence (RCT/meta-analyses), can you find qualitative studies like "lived experience of women in labor after fetal demise", or expert recommendations from ACOG, AWHONN, or CRNA/anesthesiology? Even case studies can be compelling in cases like if PTSD or postpartum depression was worsened by such practice.

Best wishes OP in your advocacy.

[klone, MSN, RN]

If, by EBP you mean randomized controlled studies, I doubt that you will find any, at least none that are current..

There is more to EBP than just randomized case-control studies.

[sharonx]

OOPS! late night typo....EBP Evidence-based practice.

[chare]

There is more to EBP than just randomized case-control studies.

Thank you, I am well aware of what evidence based practice is. However, based on the following comments, it seemed that the OP was trying to gather evidence.

…We are trying to gather EBP.

and

…but want to gather EPB if possible.

Thus the reason for my posted comments.

[Here.I.Stand, BSN, RN]

I'm not an OB nurse and have only read through half the replies... but good night. Labor has been excruciatingly painful ever since Eve gave birth to Cain.

What type of pain relief is more complete than regional anesthesia, but too risky for the unborn baby? Their rationale would make sense if one existed...but as far as I know from my own pregnancies, it doesn't. Regional anesthesia on the other hand, would no longer be a risk to the baby. So just give the poor woman the best pain relief available.

You don't need EBP to prove that these anesthesiologists are being cruel. They make me sick...no really, I'm sick to my stomach reading this. They should be reported to the medical board.

[klone, MSN, RN]

double post

[klone, MSN, RN]

Thank you, I am well aware of what evidence based practice is. However, based on the following comments, it seemed that the OP was trying to gather evidence.

and

Thus the reason for my posted comments.

How do you define "gathering evidence"? I don't equate "gathering evidence" to automatically mean "conducting a case-control randomized study". I take it to mean simply finding research, articles, etc. about best practices.

[chare]

How do you define "gathering evidence"? I don't equate "gathering evidence" to automatically mean "conducting a case-control randomized study". I take it to mean simply finding research, articles, etc. about best practices.

I'm not following this, what exactly are you trying to say?

[SHGR, MSN, RN, CNS]

This thread seems to have gone off-topic so I will post here a link to an article that delineates the heirarchy of evidence

Choosing the Best Evidence to Guide Clinical Practice: Application of AACN Levels of Evidence

The full article, which contains a chart with EBP heirarchy, is available free as a PDF.

I hope this is helpful for you, OP- we spend a lot of time in class helping each other think of other places to look and sources of the information we are seeking, even if the particular topic is out of our areas of expertise.

A PP mentioned that certainly your situation warrants going up the chain of command, but it is often helpful to be armed with evidence and logical arguments when doing so.

[klone, MSN, RN]

I'm not following this, what exactly are you trying to say?

How do you define "gather evidence"? Because the OP was saying she/they are trying to gather evidence, and you said that that she won't be able to find any randomized controlled studies. And my point is that "gather evidence" does not have to mean conduct or find a randomized controlled studies, that there is a lot more evidence based research out there that can be gathered besides RCTs.

[chare]

…Because the OP was saying she/they are trying to gather evidence…

Not exactly. The OP didn't say she was trying to gather evidence,” she said that she was trying to gather EBP. Not once, but twice.

…We are trying to gather EBP.

and

…but want to gather EPB if possible.

As I was unsure what the OP was asking I posted the following:

If, by EBP you mean randomized controlled studies, I doubt that you will find any, at least none that are current…

If you took this to mean I was suggesting that EBP equaled randomized controlled studies [trials], I am not sure how you did so, as at no time did I suggest they were. I agree that my question might have been more concise had I used gather evidence” instead.

…and you said that that she won't be able to find any randomized controlled studies…

Not exactly.

…I doubt that you will find any, at least none that are current…

For the following reason.

…you would have to assign half of your patients to receive a level of care below the accepted standard. As the epidural provides benefit to the mother, and not the fetus/neonate, I don't see how the fact that a fetal demise has occurred has any bearing and seriously doubt that any institutional review board is going to approve that.

Or are you suggesting that an institutional review board might find this ethical, not providing adequate and/or appropriate pain control to a laboring mother, because of intrauterine fetal demise? And further, provide approval?

[klone, MSN, RN]

Or are you suggesting that an institutional review board might find this ethical, not providing adequate and/or appropriate pain control to a laboring mother, because of intrauterine fetal demise? And further, provide approval?

No, I'm not saying that she should conduct primary research at all! I'm saying I'm sure there is plenty of evidence out there for her to find, and it doesn't have to be an RCT.