IV policy

SmilingBluEyes · Aug 8, 2006

saline lock in most cases.

IV only if patient plans epidural or is being induced with pitocin.

**canoehead, BSN, RN** · Aug 8, 2006

After working OB by myself at night for a couple of years I strongly recommend a saline lock in active labor. No one can predict who will have a hemmorrhage after delivery, although we know what increases your chances. If you are bleeding like a faucet, and need IV meds or fluids immediately, you have just added a 300-500 cc blood loss to your total because of the time taken to start the line- worse if it's a tough stick, or if the pt is moving around because the doc is wrist deep trying to pull placenta parts out.

The percentages say the patient will be OK without an IV, but for the 5% or so that need one I think a lock is a reasonable safety measure. After all, the percentages say you could do without the moniter, and the doc too, but most people don't want to take a chance.

RNnL&D · Aug 10, 2006

After working OB by myself at night for a couple of years I strongly recommend a saline lock in active labor. No one can predict who will have a hemmorrhage after delivery, although we know what increases your chances.
The percentages say the patient will be OK without an IV, but for the 5% or so that need one I think a lock is a reasonable safety measure.

So the other 95% get one just because. Do you have alternative routes of admin for someone who doesn't have IV access? We have standing orders for Pit IM if no IV.

CritterLover, BSN, RN · Aug 10, 2006

so, help me understand, if a pt refuses an iv, then abrupts with no warning and loses her baby, the hospital is essentially telling her it is her fault because she didn't want an iv? it would be interesting to see hwo many bad outcomes there are just because someone didn't have iv access.

i think the point in having them sign a waiver is sort of like having them sign a consent prior to a procedure. it doesn't necessarily excuse the hospital from liablility if something goes wrong, but it does show that the patient made an informed choice when she decided to forgo the iv. one less thing for the lawyers to pounce on.

fergus51 · Aug 10, 2006

i think the point in having them sign a waiver is sort of like having them sign a consent prior to a procedure. it doesn't necessarily excuse the hospital from liablility if something goes wrong, but it does show that the patient made an informed choice when she decided to forgo the iv. one less thing for the lawyers to pounce on.

i think that's completely reasonable. ob is the most litigious area of medicine/nursing. if a woman chooses not to have an iv, then that's her choice and she should own it just like she should own every other part of her birth plan. i love patients with good birth plans btw. i've worked in places where heplocks were standard and in places where an iv was started only when needed. it makes no real difference imo.

RNnL&D · Aug 10, 2006

i think the point in having them sign a waiver is sort of like having them sign a consent prior to a procedure. it doesn't necessarily excuse the hospital from liablility if something goes wrong, but it does show that the patient made an informed choice when she decided to forgo the iv. one less thing for the lawyers to pounce on.

but wouldn't charting "discussed risks and benefits, pt refuses iv", have the same effect?

CritterLover, BSN, RN · Aug 10, 2006

but wouldn't charting "discussed risks and benefits, pt refuses iv", have the same effect?

well, maybe, but do you think that would suffice prior to a c-section or placement of an epidural? at least by having the patient sign the waiver, you are having them acknowledge that they received the risks/benefits info. plus, the waiver probably has specific risks/benefits written in to it so that the nurse doesn't have to chart them explicitly. because i bet if you tell a lawyer that you discussed the risks/benefits, they are going to want to know exactly what risks/benefits you discussed.

i'm not an l/d nurse, though that area of nursing has always interested me. but it sounds kind of prudent to me, given how litiguous we all know that l/d can be, to have this kind of waiver signed. l/d is pretty unique in how they deal with mostly healthy patients, going through a normal part of life. to refuse to have an iv/sl doesn't seem unreasonable to me (i'm also needle-phobic:) ), but i think i would really like to have a signed acknowledgement of the risks in refusing the iv/sl on any patient i was caring for!

2curlygirls · Aug 10, 2006

I was just wondering how hard it would be to start an IV in an emergent situation?

SmilingBluEyes · Aug 10, 2006

How hard? Depends.......if a person is truly hemorrhaging, her peripheral circulation will begin to shunt to central (vital organs) pretty quickly---meaning veins will collapse easily as you try to gain access. Remember, minute by minute, cardiac output (in liters) in labor and immediately afterward is as much as it will ever be in a woman's lifetime. Lots of blood moving about.....lots to lose if there is an active pp bleed going on.....

Therefore, oh yes, it can be quite difficult to start a peripheral line in the case of a hemorrhaging person, particularly one who is going shocky on you. I have done it. It's no fun.

mitchsmom · Aug 12, 2006

How hard? Depends.......if a person is truly hemorrhaging, her peripheral circulation will begin to shunt to central (vital organs) pretty quickly---meaning veins will collapse easily as you try to gain access. Remember, minute by minute, cardiac output (in liters) in labor and immediately afterward is as much as it will ever be in a woman's lifetime. Lots of blood moving about.....lots to lose if there is an active pp bleed going on.....
Therefore, oh yes, it can be quite difficult to start a peripheral line in the case of a hemorrhaging person, particularly one who is going shocky on you. I have done it. It's no fun.

...plus at this time you could be needing to get methergine/ hemabate/Pit/fluids from med room, page MD back to the room, massage uterus/express clots/ continuing assessment of mom, have family members asking questions; also, it's not easy for mom to lie still during painful massage for the stick, etc. etc. etc. Just a few things off the top of my head that might be going on that you'd want to be prioritized at a time like that, over starting a line.

It could depend on your providers too... if you have me, a new nurse, I am going to take longer to get things done and intuit/ put together the situation and am not as good of a IV sticker yet in the first place either; or it could be someone with loads of experience who is just slow or disorganized anyway; or someone really great and with it who could whip it all together in any situation, KWIM?

That said, and adding that I have the nursing experience of a gnat, I can see it both ways. I wonder if there are any studies/ evidence for it either way?

We routinely get at least a saline lock on all labor pts. I'm new and haven't had anyone resist/refuse yet so I don't know the deal there.

allnurses Guide · Aug 14, 2006

IV's only with pitocin inductions or if they need meds for a positive beta strep.

Rarely a saline lock.

Low risk ob's don't get IV access at all. And our protocol is 18 gauge too - which I hate.

I think I'm with RNnL&D on this one.

steph

SmilingBluEyes · Aug 14, 2006

All it takes is for a really bad hemorrhage to wake me up. And I have seen a couple. Had to start a second line on one, and it was hard as hell. I would rather not have to gain IV access under such dire (if rare) conditions and/or situations. No thanks. Saline lock works for me. And almost all the patients have no issue with this, either.