Doula Thoughts on L&D (long)

NPinWCH · Apr 11, 2006

I've been a Labor/delivery RN for 12 years now. I was at one time also a certified doula (I let my certification lapse when I went back to work full time). I also currently teach childbirth education. I review ALL risks and benefits of interventions with my students and I tell them that they have the right to refuse any and all interventions they don't want, while making sure they understand that some interventions are needed (a baby with continuous bradycardia/late decels needs some kind of intervention).

I agree there are too many inductions, too many c sections and continuous fetal monitoring is WAY overused. I have helped attend home births, births in free standing birthing centers and hospitals. I respect my patients wishes and frequently fill in the gaps in information that the docs leave out. I feel Vbacs are a safe alternitive to repeat c sections most of the time IF the facilities are capable of responding in an emergency.

If a doc I work with says, "the baby looks good now, but we don't know how long that will last," it usually means that we have successfully used intrauterine resuscitation and the baby has recovered for the moment and it is usually followed by, "if the baby shows us anything that looks remotely troubling we will have to use the forceps/have a c section..." Pit should never be used with a baby that "might be in trouble".

I found an article referring to this study in MCN Volume 30 Issue 5 Sept/Oct 2005. I found this info really interesting and I even copied that article and posted it on my unit. It shows that all of our intrauterine resuscitation techniques do in fact raise the fetal SpO2, even O2 given to a mom with a normal SpO2 (96-100%).

http://www.greenjournal.org/cgi/content/abstract/105/6/1362

Efficacy of Intrauterine Resuscitation Techniques in Improving Fetal Oxygen Status During Labor

Kathleen Rice Simpson, PhD, RNC* and Dotti C. James, PhD, RNC

From *Labor and Delivery, St. John's Mercy Medical Center, St. Louis; and School of Nursing, Saint Louis University, St. Louis, Missouri.

OBJECTIVE: To evaluate the efficacy of 3 common intrauterine resuscitation techniques used during labor.

METHODS: Intrauterine resuscitation techniques were prospectively evaluated in healthy women during labor. Forty-two women were randomized to either a 500-mL or 1,000-mL intravenous (IV) fluid bolus over 20 minutes. Fifty-one women were randomized to 1 of 6 position sequences including supine with the head elevated 30°, left lateral and right lateral for 15 minutes each in succession. Forty-nine women received 10 L/min of oxygen (O2) via nonrebreather face mask for 15 minutes. Differences in fetal oxygen saturation (FSpO2) were evaluated before, during, and after each intervention.

RESULTS: An IV fluid bolus of 1,000 mL had a greater effect on FSpO2 than an IV fluid bolus of 500 mL (500 mL: mean increase 3.7; 1,000 mL: mean increase 5.2; P = .05). Fetal oxygen saturation was higher in a lateral position (left mean 48.3%, right mean 47.7%) than in a supine position (mean supine 37.5%, P = .03). Oxygen administration increased FSpO2 (mean increase 8.7, P = .03). The effect persisted for more than 30 minutes after the O2 was discontinued (P = .03). For fetuses with FSpO2 less than 40% before maternal O2 administration, the increase was greater (mean increase 11.4) than for those with FSpO2 of 40% or greater (mean increase 7.6, P = .03).

CONCLUSION: An intravenous fluid bolus of 1,000 mL, lateral positioning, and O2 administration at 10 L/min via nonrebreather face mask are effective in increasing FSpO2 during labor.

LEVEL OF EVIDENCE: II-2

futureTMA · Apr 11, 2006

thanks, rninwch for the information and especially your experienced view.

jrring1019 · Apr 11, 2006

NNR?? Is she referring to NPR? Room air would never be used for resuscitation.

Hypoxia is the leading cause of persistent pulmonary hypertension of the newborn. An adequate o2 level is needed to keep aveoli open.

What bothers me is that she is teaching this stuff!! I had a dad recently ask me not to use O2 on the baby after delivery. I just had the warmer set up with all of my supplies, baby was not yet delivered. He saw the O2 and said they were worried about the baby becoming blind. I did some teaching, they were fine after that and baby didn't need it anyways.

Jolie, BSN · Apr 11, 2006

As a healthcare professional and mother, I find this discussion very interesting.

But the NICU nurse in me refuses to allow a dangerous mis-statement to stand uncorrected: "In fact...when doing NNR it's been shown that resuscitating babies with room air is as effective as 100% O2..."

This is one of those "half-truths" that is very dangerous in the wrong situation. When a newly delivered infant is experiencing difficulty generating the negative pressure necessary to inflate its collapsed alveoli, but has no underlying lung or cardiac disease, it is entirely possible that PPV with room air will be sufficient to assist the infant's transition to extrauterine life. This typically applies to term infants whose airways are partially obstructed with fluid. For these babies, stimulation, suctioning and PPV on room air are perfectly appropriate measures. However, any infant that does not promptly respond to these measures must be considered to be at risk for more serious conditions which impair transition, such as prematurity, RDS, aspiration, sepsis, diaphragmmatic hernia, cardiac and lung anomolies, and must be managed in a manner consistent with maintaining an appropriate paO2, necessary to prevent serious complications such as brain injury and PPHN.

To make a "blanket" statement suggesting that room air is sufficient for neonatal resuscitation is inaccurate and dangerous.

BabyRN2Be · Apr 11, 2006

Just for those who asked: I personally know Stephanie Soderblom. She has been a doula for many years and she is training to be a midwife (CPM). I don't believe that she's had any training on the medical side of things. While she is a very nice person, she does have some very strong beliefs about the way things SHOULD be in labor. Unfortunately this spills over to everyone, her clients, friends, pregnant women on the street...

She has seen many things as a doula, but do keep in mind that she hasn't had any medical training and probably has not be named in a lawsuit. Again, I do not mean to slam Stephanie, but I just wanted to shed light on a few things and some of her considerations need to be taken with a grain of salt.

She is an awesome doula though, in fact, she's the person who first helped me start out as a doula.

fergus51 · Apr 11, 2006

If she thinks hyperoxygenating is the same thing as hyperventilating, she obviously is lacking some knowledge. She should not comment on things she really doesn't know about.

I love a good doula. I'd have one or buy the services of a doula for a friend.

fergus51 · Apr 11, 2006

As a healthcare professional and mother, I find this discussion very interesting.
But the NICU nurse in me refuses to allow a dangerous mis-statement to stand uncorrected: "In fact...when doing NNR it's been shown that resuscitating babies with room air is as effective as 100% O2..."
This is one of those "half-truths" that is very dangerous in the wrong situation. When a newly delivered infant is experiencing difficulty generating the negative pressure necessary to inflate its collapsed alveoli, but has no underlying lung or cardiac disease, it is entirely possible that PPV with room air will be sufficient to assist the infant's transition to extrauterine life. This typically applies to term infants whose airways are partially obstructed with fluid. For these babies, stimulation, suctioning and PPV on room air are perfectly appropriate measures. However, any infant that does not promptly respond to these measures must be considered to be at risk for more serious conditions which impair transition, such as prematurity, RDS, aspiration, sepsis, diaphragmmatic hernia, cardiac and lung anomolies, and must be managed in a manner consistent with maintaining an appropriate paO2, necessary to prevent serious complications such as brain injury and PPHN.
To make a "blanket" statement suggesting that room air is sufficient for neonatal resuscitation is inaccurate and dangerous.

THANK YOU!!! I don't understand how people can make statements like that when they clearly don't know what they are saying. NRP has NOT been changed to indicate all babies should be rescucitated with room air because the evidence doesn't support such a strong, blanket recommendation (yet, it may in the future we don't know). Pulse oximetry in the dr can be used to determine how much O2 to use, but that isn't the case everywhere yet.

I applaud people who feel passionately about assisting women and their families with childbirth. I am not impressed with people who make misleading statements to support their view. They often seem to want to stir up conflict.

fergus51 · Apr 11, 2006

Just for those who asked: I personally know Stephanie Soderblom. She has been a doula for many years and she is training to be a midwife (CPM). I don't believe that she's had any training on the medical side of things. While she is a very nice person, she does have some very strong beliefs about the way things SHOULD be in labor. Unfortunately this spills over to everyone, her clients, friends, pregnant women on the street...
She has seen many things as a doula, but do keep in mind that she hasn't had any medical training and probably has not be named in a lawsuit. Again, I do not mean to slam Stephanie, but I just wanted to shed light on a few things and some of her considerations need to be taken with a grain of salt.
She is an awesome doula though, in fact, she's the person who first helped me start out as a doula.

I think it's a shame she would give her opinions as fact. I've never been named in a lawsuit either and also have opinions, but I know not to pass off my opinions as medical fact (especially when medical studies don't support them).

Gompers, BSN, RN · Apr 11, 2006

THANK YOU!!! I don't understand how people can make statements like that when they clearly don't know what they are saying. NRP has NOT been changed to indicate all babies should be rescucitated with room air because the evidence doesn't support such a strong, blanket recommendation (yet, it may in the future we don't know). Pulse oximetry in the dr can be used to determine how much O2 to use, but that isn't the case everywhere yet.

I know that they are going to change NRP next year to say that we should start every baby on room air during rescucitation. But that's just to start - we're supposed to place a pulse oximeter and dial up the 02 as needed. With the lower sat ranges we're using these days, though, I don't think very many babies will require up to 100% 02 - certainly not preemies. Full term codes, there I can see it being necessary.

I was just at a conference and the speaker mentioned the room air rescucitation thing and my gosh, the audience just lit up. People were fighting with the speaker! She made some excellent points, though. Our problem is that we're using 15-year-old pulse oximeters that are very sensitive to motion and perfusion, and we never get a good reading in the delivery room. We've decided that once the new NRP guidelines come out, we're going to make the hospital purchase new oximeters that work better in the delivery room.

Sorry to hijack the thread! It's just that the idea of room air rescucitation is very exciting to me and I think I'm the only one on my unit who agrees with it.

fergus51 · Apr 11, 2006

I'm fine with it in the right circumstances, but those generally aren't the ones the doula was talking about. She'll generally be there at term deliveries, not for micropremies and like you said, it's term babies who will likely need oxygen at bad deliveries.

We had O2dials in the delivery room with pulse oxes when I was in Canada, so it isn't something completely new to me. As far as I knew though, the new NRP didn't commit to all babies starting on room air. When I went to the NICU conference in Vegas one of the speakers was a doc who worked on the NRP revisions and he said that there would be a de-emphasis of colour and encouragement to use pulse oximetry at deliveries to determine the fiO2 needed. He didn't say we'd be starting everyone at room air like this doula claims.

Have you gotten an advanced copy of the new NRP you want to share?

Gompers, BSN, RN · Apr 11, 2006

Have you gotten an advanced copy of the new NRP you want to share?

:imbar Nope. I just remember being told by both our speaker and some of our nurses who are NRP instructors that the new guidelines are going to say to start the blender at 21% and just increase as needed. I definitely agree on using a pulse oximeter rather than the baby's color, which is why I think we really need new probes! I don't agree with blowing 100% 02 in the face of every full term baby who isn't bright pink, so long as they're breathing well.

I do think oxygen is overused in the delivery room, both for preemies and full term babies.

That is about where my agreement with this particular doula ends.

fergus51 · Apr 11, 2006

I agree with you Gompers. I was actually pretty surprised when I came here and they didn't have blenders or pulse oximetry in the delivery rooms.