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.
I will say it again. The place to start is with the MDs. They are the ones calling us and coming in and wondering why we haven't started pit or placed internals so they can "prove" the contractions aren't strong enough and start pit. It is like we are in a race. I used to love to work nights because this never happened when the MDs were home asleep.
As far as pain goes, I also want to repeat that we are legally bound to ask about pain in CA every time we do vitals. In L&D, the order could be every hour in some situations--again not a thing controlled by nurses. I make sure my patients know that I am not "bullying" them into anything. I have to ask and document. They have every right to refuse and I have no personal stake in their decision.
The longer I practice, the more I feel that I am truly protecting my patients from the MDs at times. I really hate the moral dilemmas we are placed in as OB nurses. For example, pt is progressing but not as fast as MD wants. They order pit and tell pt the labor needs to speed up. I know that there is no medical basis for this decision. How do I advocate for my pt and not get myself into a whole lot of trouble. What if I talk the pt into refusing the pit and then she stops progressing and ends up with a c/s for failure to progress and it comes back to me?
Pts need to be educated about birth and also need to have a dialogue with their MD about their birthing experience long before they come to the hospital. Sadly, this doesn't happen often (at least in my area). The tone of this thread distresses me a bit because I think a lot of unfair blame is being placed on nurses when they really have very little control in a lot of the interventions. And although I agree that birth is natural and normal, not all births are safe. I have worked high risk OB long enough to have seen some true miracles brought about by timely and proper medical intervention. I have also seen perfectly natural labors turned into high risk ones by too much or improper intervention. There is no simple answer here.
Not an OB nurse, here, so I can't speak to clinical issues with any authority.
Had my son at home in the late 70's, so I do have my own bias.
I agree that nurses have little control over MD behavior and orders and are too often between a rock and a hard place.
That said ... nurses CAN control their own attitudes and behavior. Over the years on this site, I've seen quite a lot of contempt shown for "laypeople" who presume to have an opinion about how they are treated. Yes, some are unreasonable. Yes, some are badly misinformed. But the vast majority of pts and families just want to understand what's happening and have some control over decisions that affect their lives and welfare.
It takes two sides to make a situation adversarial.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
One word:
Communication.
Two ways. Always.
Really it's gonna boil down to that.
Birth plans are an attempt to communicate. If we can be respectful and understand where they are coming from, a lot of repoire and trust can be built in short time. Really, it is about attitude and communication.
Quite from Janey W's post "There is no simple answer here."
You're right. I sure wouldn't take this on by myself. However we do have a voice in NAACOG, and under that umbrella an article needs to be carefully
written and published in OB journals, regarding MD management of labor being similar to a horse race (that'll get their attention). You would have the power of numbers of nurses agreeing, and attention drawn to MD's mismanagement of normal labor. It takes courage of conviction and guts to do, so no namby pambyness will do!
Placement of the article in every OB's mailbox at hospitals, on the bulletin
boards in their lounges, nurses' lounges and on the agenda at meetings,will enhance reading of it. Once the problem of possible goal conflict is known, problem solving communication needs to happen, which is arranged with
the top administration at the hospital. This involves agreement about the bottom line objective of any delivery: healthy mom and baby. Rushing time
is only involved when s/s of distress indicate that.
When patients don't first involve their physician in their birth plans well before labor begins, it lacks credibility. I used to tell students in my classes that negotiating what they want while lying on their back, won't get their points across...... That is true for nurses, who must follow MD's orders (unless they're quite aberrant) and they cannot argue with their colleagues during and in earshot of someone in labor.
Sometimes procrastination and a feeling that nurses are more sympathetic to their wishes, (aren't we?) causes patients to bystep their physicians. I continued the example of lying on ones back, negotiating, to the examining room at the doctors' offices, cautioning them to wait until they were up and at eye level with the MD, to discuss the birth plan. Stating the obvious is also important, such as saying, "you have my birth plan in one hand, doctor, and your other hand is on the doorknob........I need to discuss it with you. Would you like me to make a special appointment with you away from this examining table, for that?" It is essential that the latter question is asked without rankor, whining, or antagonism!
Then, after the patients' discussion with the doctor (preferably with the birth coach in attendance) that birth plan or an ammended/corrected
one needs to be sent with the other paperwork from the MD's office, to the OB unit in the hospital. When the hospital OB unit is notified that the patient should be arriving soon, nurses seeing the birth plan should be sure it is read by the nurse assigned to care for that patient. That will give him/her advance warning (for example) when collection of umbilical cord blood for stem cell preservation is anticipated (off topic, let's save the example for later perusal) is on the plan. Space on the equipment table will need to be made for the sterile syringes and needles contained in an unopened plastic sac the patient brings with her. It would
be good if the MD initials that part of the birth plan to legitimize it.
i will say it again. the place to start is with the mds. they are the ones calling us and coming in and wondering why we haven't started pit or placed internals so they can "prove" the contractions aren't strong enough and start pit. it is like we are in a race. i used to love to work nights because this never happened when the mds were home asleep.
patients absolutely need to have discussions with their providers early in the pregnancy. and providers need to be more willing to have these discussions early, so that patients can find a more accomodating provider if warranted.
as far as pain goes, i also want to repeat that we are legally bound to ask about pain in ca every time we do vitals. in l&d, the order could be every hour in some situations--again not a thing controlled by nurses. i make sure my patients know that i am not "bullying" them into anything. i have to ask and document. they have every right to refuse and i have no personal stake in their decision.
in pa we are required to ask about pain hourly. however... if a patient states that they do not wish to be asked, their autonomy overrides "policy." i simply document the first time that patient explicitly states in birth plan, "i do not want to be asked about pain" (or however they have it worded verbatim). i then chart hourly my observation of their pain/coping, with a statement "pain scale deferred at pt request." that cya... you are accomodating the patient's request while maintaining your job responsibility.
the longer i practice, the more i feel that i am truly protecting my patients from the mds at times. i really hate the moral dilemmas we are placed in as ob nurses. for example, pt is progressing but not as fast as md wants. they order pit and tell pt the labor needs to speed up. i know that there is no medical basis for this decision. how do i advocate for my pt and not get myself into a whole lot of trouble. what if i talk the pt into refusing the pit and then she stops progressing and ends up with a c/s for failure to progress and it comes back to me?
i couldn't agree with the above statement more!!
you've got to do what makes you comfortable, while also taking into account your patient's best interests and wishes. i agree it's a tough balancing act. i don't know the culture where you work... how much do the mds pressure & bully the rns, do they respect your opinions, etc... wherei work, i'm not afraid to speak up and state my mind. heck, i've even done it with the head of our mfm department (who's a total a$$), and ended up with an apology from him after the patient had a prolonged decel about 10 minutes after his pitocin interventions (he never admits he's wrong to anyone...so this was a major accomplishment!!)
pts need to be educated about birth and also need to have a dialogue with their md about their birthing experience long before they come to the hospital. sadly, this doesn't happen often (at least in my area). the tone of this thread distresses me a bit because i think a lot of unfair blame is being placed on nurses when they really have very little control in a lot of the interventions. and although i agree that birth is natural and normal, not all births are safe. i have worked high risk ob long enough to have seen some true miracles brought about by timely and proper medical intervention. i have also seen perfectly natural labors turned into high risk ones by too much or improper intervention. there is no simple answer here.
personally, i'm not blaming nurses for the interventions. i am blaming some of the nurses for having such negative attitudes towards birth plans and patient autonomy. i seriously think that some of the posters have control issues that they should address.
i work in a facility that does about 10,000 deliveries/year, and many of them are very high risk. i too have seen some true miracles, and i love that interventions are available in cases when they are truly needed. i'd never suggest getting rid of interventions altogether. but we way overuse interventions in a haphazard way, causing more risks and problems than we solve. i've very rarely seen a truly high-risk patient come in with a detailed birth plan. and when a patient is high-risk with a birth plan, that's where my skills in patient education come into play. usually, after thoroughly explaining their current situation we can come to a compromise and no one's toes get stepped on.
I'm really glad you responded to me, CNM in progress. I can tell you really understood what I was saying. I went to the AWHONN convention this past summer, and it was the almost unspoken element in every session---lack of cohesion and interdisciplinary cooperation. I have spent time in a teaching hospital and had to leave because it was so depressing to see it continuing with new residents being taught and shown by example.
Right now I am working registry, so I go to many different hospitals. I definitely have those I like better than others and medical staff at some that are great and others that are almost dangerous. I am finishing my MSN this spring and hopefully will be teaching OB in nursing school starting next year. I plan to really emphasize communication, advocacy and team work. I can see that MD training isn't necessarily evolving but I am hoping to instill good communication skills, patient advocacy and evidence based practice into my students. I am doing my comprehensive exam on communication and safety in the OB setting and ways to improve that through nursing education. There has been some research but there is more needed.
We'll see if I get to the PhD level, Lamaze Teacher, and maybe I will write some research-based articles about the culture of birth in the US. I agree wholeheartedly that a wake up call is needed. I just don't know where that call should come from for the best impact. Nurses? Patients? Cost containment?
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Janey, I appreciate your perspectives. Also, I think you will answer your questions as you go along in your future advanced practices. And I think the wake-up calls you refer to will come from all the above directions, and more. But that is only my opinion, Janey. After all , if we are to have cohesion, we need to address all areas of need for our patients, our doctors and of course, our own as practicing nurses. I think you would be an excellent researcher and teacher. I wish you luck in your newest endeavors.
I also think "powertripping" is apt for describing "some" nurses' behavior and attitudes. Not going to name names or even say they are here on this site, because I think we can all relate who these folks are IRL or on the net.
But I also think I understand WHY they may do these things. We are told all the time to practice evidence-based, safe and sound nursing that would stand up to evaluation by prudent peers---- but that can be nearly impossible when physicians and advanced-level practioners refuse to practice evidence-based or even sound or safe medicine themselves in some cases. It also is hard when state and national agencies make our jobs harder everyday, without improving safety or outcomes. These things definitely and most directly affect how we nurses practice and I think a little bit of us dies when we are disallowed to do what we know is right or are disconnected from our true selves as nurses.
Not one single nurse I have spoken to in my nearly 12 years as an OB nurse (and some have done this for over 30 years) said they came into OB nursing for the money, glory, "power" or anything like that. It was a passion to care for others that drove them into nursing-----a specific passion for delivering care to birthing families that they all have verbalized to me in one way or another. Sure, money figures into it----we all have to eat and pay bills---- but the ones who stuck around 30, 35 years, did so because they believed in their ability to make a difference in others' lives.
Oh, I have read so much on this, and talked to so many who feel this pain and disconnect---- and see it all the time in my workplace. Sometimes the only "power" a nurse (often subconsciously) perceives she has is what little autonomy she either falsely or truly possesses in her work. We truly are between the proverbial "rock and hard place". We try too hard to please too many who can't be pleased, no matter what is done. It leads to stress, burnout and finally, the attitude that "they can like it or lump it--I am just gonna survive". Sad, but real.
BUT even despite all that----it gives me, in my mind, no excuse to "power trip" or disenfranchise my patients and their family members. Oh yea, the stress this can cause me to be the "in between" is sometimes tremendous, but I won't make vulnerable people pay the price for the problems I face at work that are not of their making.
I just read all 18 pages of this thread and I found it interesting as a nursing student about to enter my OB clinical and as a woman expecting her first child (completely uncomplicated pregnancy). I thought there were a lot of great points.
Unfortunately, it also made me very nervous about my own coming birthing experience. I do want a natural, unmedicated birth. I do not want a C section- but I know things happen. More than any of the interventions, I am now scared to death to have a patronizing, rude and controlling nurse such as a couple of posters on this thread. Don't get me wrong, a huge majority of posters (99%) had wonderful insightful opinions on both sides.
I am not stupid or uneducated for asking to avoid continuous fetal monitoring and opting for intermittent doppler monitoring. In fact, that choice was made based on RCTs and meta analyses of studies comparing the two methods. Being a nursing student at the moment, I am a bit obsessed with EBP (I will admit that), but all of my requests and decisions where based on my review of articles from nursing, midwifery and obstetric journals. I have also researched which problems and issues require which interventions and have no problem consenting to them in those cases, or in other cases if adequately explained.
I also know that I may be slightly more informed than some people that come in with a birth plan, or birth preferences. But I also know that all people going into the hospital feel vulnerable and want to have some say in what happens to them. People want to be heard.
Now I am thinking that I will print these articles off and pack them in my bag to bring to the hospital to back my choices up. I feel like I have to go in prepared to fight or no one will listen to me.
I only wish I had the option of going to a birthing center or having a CNM attended homebirth. Sigh.
I just read all 18 pages of this thread and I found it interesting as a nursing student about to enter my OB clinical and as a woman expecting her first child (completely uncomplicated pregnancy). I thought there were a lot of great points.
Unfortunately, it also made me very nervous about my own coming birthing experience. I do want a natural, unmedicated birth. I do not want a C section- but I know things happen. More than any of the interventions, I am now scared to death to have a patronizing, rude and controlling nurse such as a couple of posters on this thread. Don't get me wrong, a huge majority of posters (99%) had wonderful insightful opinions on both sides.
I am not stupid or uneducated for asking to avoid continuous fetal monitoring and opting for intermittent doppler monitoring. In fact, that choice was made based on RCTs and meta analyses of studies comparing the two methods. Being a nursing student at the moment, I am a bit obsessed with EBP (I will admit that), but all of my requests and decisions where based on my review of articles from nursing, midwifery and obstetric journals. I have also researched which problems and issues require which interventions and have no problem consenting to them in those cases, or in other cases if adequately explained.
I also know that I may be slightly more informed than some people that come in with a birth plan, or birth preferences. But I also know that all people going into the hospital feel vulnerable and want to have some say in what happens to them. People want to be heard.
Now I am thinking that I will print these articles off and pack them in my bag to bring to the hospital to back my choices up. I feel like I have to go in prepared to fight or no one will listen to me.
I only wish I had the option of going to a birthing center or having a CNM attended homebirth. Sigh.
:icon_hug: I had the same fears, myself. I know, it sucks.
Your conversation needs to be with your MD long before you hit the hospital. Your MD has to order intermittent monitoring and you need to not be induced with cytotec or pitocin. You don't have to fight. Just don't wait until you are there. Get the orders in advance from your MD and don't get induced unless there is a true medical reason for it.
Your conversation needs to be with your MD long before you hit the hospital. Your MD has to order intermittent monitoring and you need to not be induced with cytotec or pitocin. You don't have to fight. Just don't wait until you are there. Get the orders in advance from your MD and don't get induced unless there is a true medical reason for it.
Unless there is a medical reason for it, why would a woman be induced? And whatever happened to a patient's right to choice their desired treatment?
We offer patients the right to choose if we will restart their heart, we offer them the right to die with dignity, yet we want to tie women to the bed and not offer them choices as to how to give birth.
Unless there is a medical reason for it, why would a woman be induced? And whatever happened to a patient's right to choice their desired treatment?
We offer patients the right to choose if we will restart their heart, we offer them the right to die with dignity, yet we want to tie women to the bed and not offer them choices as to how to give birth.
What is society coming to?
UNFORTUNATELY... the system is totally backwards!! Some women call the shots and get elective inductions, just because they want the baby on a certain day, or they want to make sure their favorite OB is on call, or they're tired of being pregnant, or the moon and sun are in perfect alignment with the 5th moon of some obscure unnamed planet... But when a woman is educated about interventions and risks and comes in with a birth plan, we find that woman to be pushy, demanding, controlling, insert your own adjective, and we (nurses, MDs, etc...) have problems with it! Am I missing something here?
Some women call the shots and get elective inductions, just because they want the baby on a certain day, or they want to make sure their favorite OB is on call, or they're tired of being pregnant, or the moon and sun are in perfect alignment with the 5th moon of some obscure unnamed planet... But when a woman is educated about interventions and risks and comes in with a birth plan, we find that woman to be pushy, demanding, controlling, insert your own adjective, and we (nurses, MDs, etc...) have problems with it! Am I missing something here? 
JaneyW
640 Posts
I will say it again. The place to start is with the MDs. They are the ones calling us and coming in and wondering why we haven't started pit or placed internals so they can "prove" the contractions aren't strong enough and start pit. It is like we are in a race. I used to love to work nights because this never happened when the MDs were home asleep.
As far as pain goes, I also want to repeat that we are legally bound to ask about pain in CA every time we do vitals. In L&D, the order could be every hour in some situations--again not a thing controlled by nurses. I make sure my patients know that I am not "bullying" them into anything. I have to ask and document. They have every right to refuse and I have no personal stake in their decision.
The longer I practice, the more I feel that I am truly protecting my patients from the MDs at times. I really hate the moral dilemmas we are placed in as OB nurses. For example, pt is progressing but not as fast as MD wants. They order pit and tell pt the labor needs to speed up. I know that there is no medical basis for this decision. How do I advocate for my pt and not get myself into a whole lot of trouble. What if I talk the pt into refusing the pit and then she stops progressing and ends up with a c/s for failure to progress and it comes back to me?
Pts need to be educated about birth and also need to have a dialogue with their MD about their birthing experience long before they come to the hospital. Sadly, this doesn't happen often (at least in my area). The tone of this thread distresses me a bit because I think a lot of unfair blame is being placed on nurses when they really have very little control in a lot of the interventions. And although I agree that birth is natural and normal, not all births are safe. I have worked high risk OB long enough to have seen some true miracles brought about by timely and proper medical intervention. I have also seen perfectly natural labors turned into high risk ones by too much or improper intervention. There is no simple answer here.