Fundal pressure

Wow, that's a lot.... Deb or Betts or another more experienced poster will be able to help you better, here's my take-

Fundal pressure- NEVER! I've never seen complications firsthand becuase it is not done where I work. It does not meet any standard of care and I don't believe the doctor asking for could, if asked, come up with any current lterature supporting fundal pressure as a safe means to expedidite delivery.

Epidurals- ours have Fentanyl and Bupificaine, and I'm not sure of the amounts of each drug in the im epidural mix. If that info would still be helpful to you I can get it though.

Our MDAs place a combined intrathecal-epidural, the patient gets 1-3 hours of really dense, excellent pain relief with the intrathecal, and he places the epi catheter through the same puncture. Tapes up her back, stays around awhile to make she it's working & she's ok, and then it's just us again. Pt has a self-bolus button, and we can turn the epidural rate up and down within a range written in the epidural orders. The providers have often timed the initiation of the epidural well so that pt gets epi, sleeps through labor, wakes up a little less comfortbale, we check her, she's either fully or close to it but the head is still a bit high, so we encourage her to bolus herself once or twice to get comfortable and labor down. then the timings usually perfect to start pushing! Sometimes we need to decrease the rate or stop the epidural altogether during pushing, if mom's bottom is still too dense. We will rarely have a vacuum assisted birth, but never a forceps. I did finally find them in our storage room though. But no one ever uses them. Someone who's been there 20+ years said that SHE'D never seen a forceps delivery in our hospital!

With your epiduralized pts, are you allowing them time to "labor down" before they start pushing?

Wow, I can't believe that you have never used forceps?!?! Not that I feel that they are a good thing, but I would be willing to bet that we use them everyday where I work. UGH! Mostly due to the fact that it is often that our patients can't feel to push effectively. I can't tell you the number of times that I have had physicians come into my room and when the patient tells them that they are feeling some pressure I'm told to get the pt a boost! I'm thinking..... YES! Pressure! The M.D.'s seem to want their patient's paralyzed! Our clientele seems to think they should have an absolutely sensation-free childbirth experience. I try to reinforce in the beginning that pressure is their very best friend! I tell them that it is my hope that they feel some pressure in the end and that there is nothing more frustrating to them and to myself when they are not able to push because of lack of sensation. A lot of them buy it if I can keep the darn docs out of my room! We are not supposed to touch the epidural pump at all. But I have certainly been known to turn it off. One time it backfired on me when the patient ended up with a forcep delivery because the doc was impatient which is usually the case. So she was beginning to get some feeling back and was in a lot of pain with the forceps! A NIGHTMARE! Ended up with a pudendal.

As far as letting the patient labor down.... of course! I would love to do just that with each and every delivery. If someone progresses relatively quickly during the weekdays while the docs are in the office and before the end of office hours, laboring down works just fine. However, let's say you have a primip who comes in for in for induction and is complete and -1 at 1700. You had better start pushing because the docs are not going to stand for you sitting a complete patient up in the bed when they are ready to go home for the day! If you are pushing for more than one hour then they are in your room asking your patient if she is "tired" and "wants some help." Translation: I want to drag your baby out of you with forceps or vacuum so that I can get my butt to the house! Also... very commonly we have a mass migration to the c-section room at five for "failure to progress." It is infuriating! What's worse is that I work fri, sat, sun each week and you can be assured that these pampered lazy-butt docs have other things planned on their call weekends! They are constantly in your room checking your patients. "Increase the pit!!!!!" I had one who ordered for me to push an 8-9 cm twin gestation multip yesterday! He called her complete. I was about to push her when I felt a rather large rim of cervix all the way around! I confirmed this with another nurse. She left to call him and he said... "push!" So I increased her pit and complained a bit with the nurses at the desk... then went back... wasted about 30 minutes. She was just nearly complete and I pushed. Only for about 20 minutes and had the baby crowning. BUT... they rush us like crazy!!! When they call a patient complete... it's time to PUSH! Regardless of station! This is a very real problem, especially on the weekends. HELP! It has always been my goal to give my patient's a respectful childbirth experience that is as close to their ideal as possible. But the docs seem to mess it up all the time! Also... We have several docs that cut epis. regardless of needs. Before even assessing for the need! I now tell them ALLLLLL when they come in the room for delivery that the patient is trying to avoid an epis. Would you believe that we got those 37.3 week twins out last night with an intact perineum... even after forceps! Everyone in my room was in utter SHOCK and awe! T.