Yes, I'm old and rickety...but, I HATE birth plans!! Especially those that include NO vag exams unless she needs to push (wth), or NO IV access (wth), or NO fetal monitoring (WTH!!) etc.....
It just annoys me to no end that a girl comes in and tries to tell me what is best for her and her unborn baby, and totally interferes with efforts to keep her and her baby safe.
Then there is the sig other that really annoys me by being the patients mouth piece. "No, she doesn't need pain meds", or "No, she doesn't want to lay off of her back".(when having variables down to 60x60...UGGGG!!
These people need to just have their babies at home, and leave my nursing license out of it!!!
Anyone else bothered by birth plans? Maybe it's just me.
For 35 years I taught prenatal classes and worked with expectant moms, dads, grandmas, etc. on Birth Plans. Most didn't do them! What's happened that spurred this influx of them?
I did tell them that all bets were off if their baby or mom got into medical difficulty, and if the nurse told them that the FHTs weren't indicating normality. I also told them unequivocally to lie on their sides, never their backs, especially if/when they perceive extreme back pressure with contractions, which could indicate posterior presentation.
All causes for c/s were understood, and no one wanted a "bad outcome" without one. The "coach" is the advocate for women having a contraction and knows her reactions to pain better than anyone. If she's doing her breathing, she's "in control", I told them, if she's writhing, screaming and/or begging for an epidural, she's not "in control" and does need medical intervention. The more they practice techniques, the better utilized they are.
I was invited to explain prepared childbirth to Sally Field for her "All in the Family" birth. I was thrilled when she completed breathing through a "contraction", then turned to the writer who wanted her to say something while having "contractions" and said, "I can't talk while I'm having a contraction!"
As nursing in any specialty requires, a friendly, cooperative nurse who understands patients' needs to be empowered is best. Predicting dire outcomes as a means of telling them who's really in charge isn't rickety, it's nasty! My patients/students never failed to teach me a lot.
Deb-You are absolutely right. If a lot of these women were told why they were getting something instead of "You have to have xyz or your baby might have a bad outcome . . . . . ", (especially if it's an unlikely and worst-case scenario) they would be a lot easier to work-with. Not every birth is the same. There should not be cookie-cutter treatment for all of them.
There's a big difference between being ready for an emergency and treating every case like it already is one. It would be like me aggresively treating every chemo patient like they're pancytopenic. Or like treating every IV infiltrate like an extravisation. Or every IV fluid spill like a chemo spill and bringing the guys up in their Haz Mat outfits.
Instead, we monitor daily labs to see if the pt's numbers are trending down. Watch the actual patient for S/S of low blood, platelet or white counts. Watch for S/S of infection. I look at what fluid infiltrated. I check the pt's veins and if they're crappy I put in for a PICC consult.
It's like these ladies are being treated like the monitored patient that is restless or complaining that something doesn't feel right, starting to get dusky, a little puffy, or getting rales, but every thing looks okay on the monitor so they must be fine. Meanwhile you look at their ABGs and they come back looking crappy. Look at your patient and treat appropriately!
I am sorry to say this, but your examples, although valid for med/surg, do not relate well to L&D. Many of the patients come in w/o pre-natal care and w/o histories. Some "omit" crucial facts from previous birth histories for various reasons. Your "normal birth" patient becomes an emergency in the blink of an eye. If you want to keep your license and stay true to your nursing training, you will do well to do comprehensive assessments on all your patients, but in many situations it is not possible. In a large specialty facility or a birthing center, you might have the flexibility and the staffing ratio to allow for one on one care and establishing a personal relationship with the mother to be before she ever comes in labor. The rest of the time, working in L&D is comparable to working in ER. There simply isn't enough time to go into in-dept explanations of why your suggested interventions are medically necessary and how the otcomes are related in the bigger picture of having a SAFE delivery versus the birth plan's "I want everything just so no matter what you say". Come to think of it, sometimes it reminds me of working in Psych ER.
I did not mean to unload on you, though. I am just frustrated about how polarized the opinions posted in this thread have been. I think birthing plans are meant to be a communication tool, and communication, as we all know is a two-way street. (I am leaving the third party, the MD's, out. After all, this is a disscussion between us, nurses and to possibly benefit our patients).
I am sorry to say this, but your examples, although valid for med/surg, do not relate well to L&D. Many of the patients come in w/o pre-natal care and w/o histories. Many "omit" crucial facts from previous birth histories for various reasons. Very often, your "normal birth" patient becomes an emergency in the blink of an eye. If you want to keep your license and stay true to your nursing training, you will do well to do comprehensive assessments on all your patients, but in many situations it is not possible. In a large specialty facility or a birthing center, you might have the flexibility and the staffing ratio to allow for one on one care and establishing a personal relationship with the mother to be before she ever comes in labor. The rest of the time, working in L&D is comparable to working in ER.
How many of your patients actually come in with no PNC or no hx (do your OB offices send a hx to L&D at 36 weeks)? If it's a significant percentage, then you are working with a unique population that should be treated as high-risk in many circumstances. But I question whether it's a significant number or not.
You state that "very often, your nornal birth patient becomes an emergency in the blink of an eye." I don't have statistics at hand, but if I remember correctly, it's less than 5% of births becomes emergencies. And most of those are ones that are intervened with (inductions, pitocin, cytotec, cervidil, stadol, epidural, AROM). Do those numbers justify treating every patient as an emergency waiting to happen? I work in a facility that does 10,000 deliveries/year. We certainly don't have one-to-one nursing, and we are ALWAYS short-staffed. We have a higher-than-normal number of high risk pregnancies because they are referred to us from the tri-state area. I've seen the worst-case scenario on a regular basis. And I still will argue that not every woman needs monitoring, IVs, etc...
Working in L & D is not like working in the ER...we only make it that way with our policies and routines. We treat pregnant women like an emergency situation, but they really aren't.
Quote from RNisvocation1st: "although valid for med/surg, do not relate well to L&D. Many of the patients come in w/o pre-natal care and w/o histories. Many "omit" crucial facts from previous birth histories for various reasons."
How many of the underlined patients have their Birth Plan in hand upon admission? I would guess none, or if there was one, it might have nothing to do with reality. What many Birth Plans indicate, is the state of apprehension your patient is in, how much she comprehended in her classes or other preparation, and especially how she thinks of medical/nursing personnel.
Just as you took issue with the m/s examples, you've strayed from the topic when introducing the medically indigent type of patient. They are diametrically opposed to the type of person who attends prenatal classes or reads about Birth Plans and diligently attempts to communicate what might make her more comfortable.
And wouldn't it be helpful in m/s to know, in a patient composed note, what scary expectations lurk in your patients' minds, what things make them more comfortable, and how they'd like to be approached (first or sir name?, door/screen open or closed? explanations before doing stuff to them, what is the result/objectrive of the treatment they're having?)?
For heavens sake! Nurses, arguing about something that is meaningful to your patient who is about to have what can be a very frightening experience for them, is counter productive. Seeing a Birth Plan as something you belittle, would rather not spend time reading, or a reflection of how stupid the childbirth educator was to suggest it doesn't give patients confidence in you. Taking them seriously does.
Remember that the patient "is the most important member of the health care team". It's the world according to them that must be heard (between contractions) for a cooperative working relationship to happen. We're their "front line" of care.
Be empathetic. Birth Plans have survived for 35+ years, they're not going away because they don't suit you or you like ridiculing patients' less informed attempt to get with the program, despite their concerns/fears/panic.
For heavens sake! Nurses, arguing about something that is meaningful to someone who is about to have what can be a very frightening experience for them, is counter productive.
Remember that the patient "is the most important member of the health care team". It's the world according to them that must be heard (between contractions) for a cooperative working relationship to happen. We're their "front line" of care.
Be empathetic. Birth Plans have survived for 35+ years, they're not going away because they don't suit you or you like ridiculing patients' less informed attempt to get with the program, despite their concerns/fears/panic.
HAPPY 2009, Y'ALL!
AMEN!!
I welcome birth plans, because it gives me insight into what this patient wants, fears, values. What I don't care for is the attitude that some couples with birth plans have as soon as they enter the door. They come in with fists swinging, ready to fight tooth and nail for what they want. They don't take the time to assess the nurse to see if they NEED to fight for what they want. I understand completely why they are that way, even more so after reading the attitudes of many nurses here. As a nurse who will fight tooth and nail to get them the birth they desire, it's sometimes frustrating as you try to break through the wall they have surrounding themselves.
My first birth I was bullied into pitocin, staying in bed, antibiotics, epidural, Stadol, etc. B/c my water was broken for 4 hours. (with contractions) I have unpleasant memories of dd's birth. I learned. My next birth I showed up ready to push. No time for all that other stuff. I had a great experience. Not everyone wants drugs and interventions, and homebirth may not be an option for them. (long distance to hospital if something goes wrong, insurance reasons, midwifery illegal in their area, etc.) I don't understand why patients can't have say in their medical care, especially when there isn't proven risk to what they want/want to avoid.
I don't understand why patients can't have say in their medical care, especially when there isn't proven risk to what they want/want to avoid.
Not only is there no proven risk to their choices, their choices are proven to have LESS risk than what they get bullied into!!! I argue with co-workers all the time who say that childbirth is SO dangerous. No it isn't. Our interventions in childbirth are dangerous.
Irks me bad when the plan includes "please respect my privacy and knock before entering my room"DUH!
That one does bug me slightly, but only because our L & D rooms are HUGE, with an "entryway" and a curtain before entering the patient's actual room. If I were to knock, they probably wouldn't even hear me.
My first birth I was bullied into pitocin, staying in bed, antibiotics, epidural, Stadol, etc. B/c my water was broken for 4 hours. (with contractions) I have unpleasant memories of dd's birth. I learned. My next birth I showed up ready to push. No time for all that other stuff. I had a great experience. Not everyone wants drugs and interventions, and homebirth may not be an option for them. (long distance to hospital if something goes wrong, insurance reasons, midwifery illegal in their area, etc.) I don't understand why patients can't have say in their medical care, especially when there isn't proven risk to what they want/want to avoid.
I understand what motivated your actions with your second birth, but wish there had been an effort to discuss with the staff at that hospital, between the two births what their interventions made you do. Your doctor would have had to leave the orders for the medications you were given, so it would have been good to start with him/her. Some hospitals no longer allow "standing orders" in OB.
So many OB nurses and doctors try to second guess how labor will go, if certain protocols aren't followed and they're invariably wrong. It also seems that, unless your first birth happened 30 years ago, the staff hadn't a clue
about developments such as walking for frequent contractions, as long as the baby's head is firmly in the "true" pelvis, without pressure on the umbilical cord, after the mambranes rupture.
I imagine someone ruptured the amniotic sac (broke the water bag) or it ruptured spontaneously, with the baby's head high, and when spontaneous contractions didn't ensue in a few hours, pitocin and antibiotics were needed, as well as bed rest. Since the baby's head may have been high, fear of the umbilical cord dropping alongside it as it dipped into that narrower channel, or worse still, below it, causing fetal distress and an emergency c/s. The epidural seems a little much, unless the staff thought you'd progress faster if you were more relaxed, and you were resisting the contractions by tensing up, which can lengthen labor. Did you learn relaxation in your prenatal classes?
You were very fortunate that your second birth went without mishap. However it could have been a good learning
opportunity for your doctor, and the nursing staff if you'd done some lobbying close to the end of your second pregnancy, to set the scene for less/no intervention, unless you or your baby were actually in trouble. I'm vehemently against home birth, as I've seen how quickly hemorrhaging women can "bleed out". Hospitals have gone to great effort and expense to bring "home" into the hospital to make it more consumer friendly.
When I was pregnant with my son, 36 years ago I wanted to have him in hospital, but get the heck out of there as soon as I could, to recover in the familiarity and comfort of my own home. I knew about a project Kaiser Permanente in San Francisco was doing, with 20 "low risk" women a month who attended classes to become very aware of post partum monitoring and complications. As much as possible, those families were discharged home 4 hours after the birth, as long as mom's bleeding was slowing and she had urinated; and the baby's VS were good, he/she'd urinated and suckling was established.
A Home Health Nurse with OB experience met them at the door of their homes as soon as they got there, checked mom and baby, observed the support they had from family and how well the baby fed. s/s of jaundice were reviewed; and it was agreed that if that happened the baby would come in for testing and be exposed to natural light at home. A Home Health Nurse made another home visit on the 3rd pp day, and more prn. "Early home discharge was decreed a success. Other communities instituted it within 24 hours with 1-2 pp home health visits.
They hadn't heard about it in Los Angeles, where I moved to remarry and became pregnant. So in my 3rd trimester I discussed my "birth and pp plan" with my physician (who was so preoccupied with the increased cost of his malpractise insurance, that's all he wanted to talk about). He said if it was OK with my pediatrician, he'd "go
along with it." So I discussed it with him, and met resistence. "What if he got jaundiced?", asked that astute MD.
Since he knew of my OB and Nursery/NICU experience, I responded, "Do you think I wouldn't notice that?" Luckily he wasn't on staff at the hospital where I planned to deliver......since I lived in the South Bay and he practised in Beverly Hills. However, I went to the chief of Peds at the South Bay Hospital. He said the baby wouldn't be discharged if his temperature was low, and I concurred. Then I discussed it with the Nursing staffs of each shift at the hospital where my physician was on staff, individually, describing Kaiser's successful program. They got it!
Planning is everything......
Labor went well, and to my utter surprise and protestation that even though I am a prenatal Lamaze educator, I wanted to have medication if I asked for it; and when I was told that I could "push", I said "no it isn't, I haven't had medication yet". I was gently convinced by my wonderful nurse that I was at 10cm, and tentatively, then with more conviction I painlessly, with my perinium/"elevator" in the "basement" (as I taught pelvic relaxation), brought him down and controlled expulsion to the OB's direction. We went home 6 hours after David was born, to the amazement of my neighborhood, whose women started their ovens. My husband was thrilled by the total hospital bill of $250. At that time (1973) no health insurance companies paid for care of pregnancy,
childbirth or pediatric care before 10 days! Their method of birth control.
I understand what motivated your actions with your second birth, but wish there had been an effort to discuss with the staff at that hospital, between the two births what their interventions made you do. Your doctor would have had to leave the orders for the medications you were given, so it would have been good to start with him/her. Some hospitals no longer allow "standing orders" in OB.
So many OB nurses and doctors try to second guess how labor will go, if certain protocols aren't followed and they're invariably wrong. It also seems that, unless your first birth happened 30 years ago, the staff hadn't a clue
about developments such as walking for frequent contractions, as long as the baby's head is firmly in the "true" pelvis, without pressure on the umbilical cord, after the mambranes rupture.
I imagine someone ruptured the amniotic sac (broke the water bag) or it ruptured spontaneously, with the baby's head high, and when spontaneous contractions didn't ensue in a few hours, pitocin and antibiotics were needed, as well as bed rest. Since the baby's head may have been high, fear of the umbilical cord dropping alongside it as it dipped into that narrower channel, or worse still, below it, causing fetal distress and an emergency c/s. The epidural seems a little much, unless the staff thought you'd progress faster if you were more relaxed, and you were resisting the contractions by tensing up, which can lengthen labor. Did you learn relaxation in your prenatal classes?
You were very fortunate that your second birth went without mishap. However it could have been a good learning
opportunity for your doctor, and the nursing staff if you'd done some lobbying close to the end of your second pregnancy, to set the scene for less/no intervention, unless you or your baby were actually in trouble. I'm vehemently against home birth, as I've seen how quickly hemorrhaging women can "bleed out". Hospitals have gone to great effort and expense to bring "home" into the hospital to make it more consumer friendly.
My water broke and contractions started at the same time. I was progressing quite well. Just not 1cm an hour. More like 1cm every 2 hours. I got the message they just wanted to get the labor/delivery over with. The dr. kept mentioning "speeding things up for you." and would get annoyed when I would state I was in no rush. That birth was only 3 years ago. I don't put any "blame" on the staff nurses. They were mostly ok with whatever I wanted. It was the OB that was the issue. I am over it though. I don't go to that hospital or OB anymore. I see a group of CNM's at another hospital.
lamazeteacher
2,170 Posts
For 35 years I taught prenatal classes and worked with expectant moms, dads, grandmas, etc. on Birth Plans. Most didn't do them! What's happened that spurred this influx of them?
I did tell them that all bets were off if their baby or mom got into medical difficulty, and if the nurse told them that the FHTs weren't indicating normality. I also told them unequivocally to lie on their sides, never their backs, especially if/when they perceive extreme back pressure with contractions, which could indicate posterior presentation.
All causes for c/s were understood, and no one wanted a "bad outcome" without one. The "coach" is the advocate for women having a contraction and knows her reactions to pain better than anyone. If she's doing her breathing, she's "in control", I told them, if she's writhing, screaming and/or begging for an epidural, she's not "in control" and does need medical intervention. The more they practice techniques, the better utilized they are.
I was invited to explain prepared childbirth to Sally Field for her "All in the Family" birth. I was thrilled when she completed breathing through a "contraction", then turned to the writer who wanted her to say something while having "contractions" and said, "I can't talk while I'm having a contraction!"
As nursing in any specialty requires, a friendly, cooperative nurse who understands patients' needs to be empowered is best. Predicting dire outcomes as a means of telling them who's really in charge isn't rickety, it's nasty! My patients/students never failed to teach me a lot.
Happy 2009 and may everyone enjoy their work!