epidural - who has the right to decide?

Anesthesiologist, he is giving the drugs not the MW. If she/he, the MW, would like to take the courses and get the certification for a nurse anesthetist, fine so be it, they can push the drugs themselves. Until the MW takes the courses and gets the required licensure its all about the anesthesiologist.

Hi This Is Just Y Idea From Experience.we Work As A Team,no One Thinks He/she Is A Better Worker.we Give Our Reasons As To Why Yes/no And Then Decide Which Is Rational.but Most Mothers In Labour Prefer It On So The Patient Has A Right Too.

Yup, the MDA has the final say in anesthesia. And believe me, there have been some heated discussions between the docs and the MDA's about what is "best" in the second stage!

Where I work, the MDA and OBs seem to come to agreements w/o it coming to blows. I think some clear communication and teamwork are what is needed to head off such conflicts. Our MDAs are very willing to allow epidurals to be turned down or even OFF by our OB's if they need to-----but then they work together, not antagonistically, most of the time.

I'd say the OB or RN but then again I'm bias. Our MDA's really try to make too many policies on our floor.

They run around telling my patients not to drink any water in labor. They also have recently taken over all orders for anti emdics. So I'm suposed to call them even if my OB has given me an order for zofran.

It's really frustrationg because it all stems from a problem they have with RN's haveing too much autonomy on our unit. I offten have MDA's try to tell me how to titrate my pitocin. I've even had them try to tell me how to position my patient to push. They try to run in and catch precip babys. Some of the OB's have even started to get frustraited with them. It's very annoying to have a MDA that explains everything about labor to your patient (incorrectly) when the OB is standing right there.

Sorry, sore spot for me....

DayRay:

Do you work with me?chuckle Your people sound like our people. Not only do they want the final say in just about everything, they are waiting like vultures to talk with new admits, wanting to promote the epidural and asking "if not, why not?" to those who choose to go without.

We've had a huge problem, but thankfully, we have a very strong manager who is more than willing to take them on as a group. They leave their unused drugs on their carts, expecting us to take care of them and then get really nasty when we tell them they have to waste and co-sign, just like the rest of us.

Our OB's decide when and if to turn down or off an epidural. If that happens, the gas-passer is then notified, but so far we haven't had any big to-do's over that one. But lots of other control issues come up all the time.

Thanks for your responses. I'll elaborate what happened with me.

The midwife examined the pt, says she's ready to push, and my preceptor asked me (still under orientation) to call the Anesthesiologist, who is a resident(don't know if they are called MDA at this point). I am in a teaching hospital, full of new interns and residents.

Anyway, Anesthesiologist came in, lowers the epid, but but not as low as the midwife wanted. There was a lot of tension, with the RN taking the side of the anesthesiologist (can you say passive aggressive?), stating that the pt is in pain, and therefore the epid. shouldn't be lowered. Being the only person able to speak to pt's language, I knew that the midwife had done a pain assessment (she was in no pain at that point, even though the contractions were coming strong), but the RN and the anesthesiologist did not.

Taking aside how I would approach this (NOT this way) my additional question to you all is this - given that the pt says she is no pain, and ready to push, what are your thoughts on lowering the epidural? Does it help to give the mother more sensation and control over her pushing if the epid. is lowered? For those of you with years of experience what do you think?

Only a few years experance here but I'll give my opion.

Yes lowering the epidural can make a patient deliver faster. I don't have mine turned down offten because most patients are able to learn how to push with an epidural it just takes time.

Still though most are able to push just fine even with dense epidurals. Some don't push well but would tottaly freak out if you turned down the epidural. I have seen patients who had epidurals turned down freak out and absolutly refuse to push because they are out of control in pain.

So really it's not a decistion I make offten. If I think it will make that big of a diffeance I talk to the patient about it and see what they think. C/S due to poor pushing is a risk of epidurals and patients should be able to choose to take that risk if they would rather have a c/s then pain.

I have had the opperunity to take care of allot of medicated and non medicated patients. If you properly guide and support your patient I think epidurals only add 20 min to 1 hour of pushing and in some cases reduce the time it takes to push babies out. For msot patients a longer pushing time without pain is preferrable to a short hurendusly painful delivery.

this is where laboring down comes in. I do not want to make a woman push for hours on end just cause she is complete......often when the baby gets REALLY low, they feel lots of pressure and will push well w/some good coaching and help.

this is where laboring down comes in. I do not want to make a woman push for hours on end just cause she is complete......often when the baby gets REALLY low, they feel lots of pressure and will push well w/some good coaching and help.

Laboring down, interesting... must explore that, thanks. If it shortens pushing time without hurting the baby or mother, why not? Do you position the mother upright? I saw a nurse prop a mother up in bed to help her labor down, which at time, I didn't know what it was.

ps. you guys are great.

Home births are fairly common here; we see a few that have not gone as planned come in for care. But these are generally NOT the folks who will have epidurals, anyhow. They either deliver lady partslly with the help of our on-call OB, or go to section if things are really going wrong. We just had a case of undiagnosed twins (the midwife had no idea the mom was having twins) take our OB by surprise not too long ago. To say he was not happy, would be an understatement.