L&D - advocating for patients

trauma_lama, BSN · Jul 22, 2011

ooh no experience here but can't wait to see some of the responses... :smokin:

RNperdiem, RN · Jul 22, 2011

That is one reason I stay far away from L&D.

Drugs for pain control are embraced in SICU, natural is not always considered a good thing, and differing political agendas/worldviews are less of an issue.

I'm curious to hear responses too.

Trauma Columnist · Jul 22, 2011

Moved to L&D forum.

Trauma Columnist · Jul 22, 2011

Moved to OB/GYN forum.

adpiRN · Jul 22, 2011

Yes we see this a lot.

Some patients don't care at all, other ask questions and request more time.

Doctors give explanations like "Your contractions have spaced out/don't seem strong enough/you're still 3cm/4cm/5cm" I'd like to start some pitocin because we don't like labor to go on too long once your water's broken (even if they're the ones who broke the water!!!!) Most patients (unless they're committed to natural) do want a shorter labor so they agree.

Patients who want natural are harder for the OBs to convince, but they usually do. Especially if they break down and get an epidural.

Once you get an epidural you're sort of at their mercy.

If you come in contracting every 10 min at 2cm and demand an epidural they will DEFINITELY pit you.

It's frustrating. We can try and advocate, but we never win, so it just seems like a waste of energy to care.

One thing I try and do is if they suggest augmenting with pit just based on contraction pattern, I urge them to check her and see if she's made change. Sometimes they're fully from contractions that were 4-5 minutes apart. So in that case, who cares how far about they are?!

Once patients arrive in L&D for induction it's too late to do anything about that, though it's interesting and frustrating to hear the stupid explanations "My doctor thought because my due date is tomorrow and the baby seems big, that I should be induced today..." They just don't get it.

The only time we can intervene there is if we're in triage. I saw one triage nurse advocate for that. The pt came in (rule out rupture, which was ruled out) and not really in labor. The OB said "Let's just keep her" meaning "induce her" b/c she was 40 weeks. But the pt wanted to go home! The nurse pointed this out. The OB acted all huffy about it, but finally agreed to let her go.

What annoys me more than pit is probably AROM. Once they break the water they're on a clock. So AROM too early can lead to a c/s for infection or failure to progress. I've also seen AROM twice directly leading to emergency c/s from occult prolapsed cord.

Once I had a patient preterm (Maybe 34 or 35 weeks...) In early preterm labor. She was dilating, but still early. After 34 weeks we don't stop preterm labor, but we also shouldn't be helping her along. The OB came BROKE HER WATER and the PITTED her. I wanted to vomit. I tried to fight it - charge nurse, manager, chief resident. But they said that although he shouldn't have broken her water, now that she's ruptured, she's committed to delivery, so start the pit.

AJPV · Jul 22, 2011

adpiRN - thanks for your thoughts! In your experience, does initiating an epidural usually slow down labor to the point where pit is usually necessary?

I think this shows why it is SO important for patients to seek out at least some basic science-based medical knowledge so they're prepared to make intelligent choices.

nohika · Jul 22, 2011

I think this shows why it is SO important for patients to seek out at least some basic science-based medical knowledge so they're prepared to make intelligent choices.

I think this has two sides, though. If they were going through medical journals (reputable ones) - sure. But for a lot of laypeople, "basic science knowledge" comes from Dr. Google and is the bane of so many healthcare providers when patients get stuck with "whatever Google said".

Tbh, I can't totally blame doctors. They know that /one/ case where /something/ goes wrong and they could have done something but elected to go au natural or whatever and the baby dies/is maimed/whatever, it's their butt slammed with a lawsuit before they can blink. Go America.

AJPV · Jul 22, 2011

nohika - I agree. It's important that we teach our patients where they can find sound medical info (not "Dr. Oprah"). But I guess what I'm saying is that if a woman is having an effectual progressing labor pattern, reassuring fetal heart rate tracings (no late or excessive variable decels), she's not post-term, no PROM, no evidence of chorio, no Rh-isoimmunization, no pregnancy-induced HTN, etc., I think she should question an MD's advice to AROM or to induce/augment. That MD should not be offended when asked to provide real reasons that are acceptable according to standards of practice.

lrobinson5 · Jul 23, 2011

adpiRN - thanks for your thoughts! In your experience, does initiating an epidural usually slow down labor to the point where pit is usually necessary?
I think this shows why it is SO important for patients to seek out at least some basic science-based medical knowledge so they're prepared to make intelligent choices.

I haven't done my OB rotation yet, but is there a reason to NOT give pitocin once you have an epidural. The biggest mistake I eve made was letting the doctor start pitocin. I wanted to try and go natural, but after 7 hours on a pitocin drip I gave up and got the epidural. After that they were able to give me a lot more and I delivered less than 30 minutes after the epidural (went from 4cm to 10 in that time). I thought that the discomfort was the main deterrent from starting the pit, is it also harmful to mother or baby?

adpiRN · Jul 23, 2011

Not, it's not harmful. (at least not that they know of!). Though I've heard some say it causes issues with milk production, but I don't work postpartum not sure about that.

It CAN cause fetal distress if it works TOO well and causes lots of strong contractions. But in that case it can be turned off and rapidly resolves. In rare cases you can have a c/s for fetal distress from pitocin.

To the OP - epidurals can slow down labor especially if given too early, before a regular labor pattern is established. Doctors actually advise women who are in early labor, contracting irregularly and less than 3cm dilated to go back home or go walking.

But sometimes they BEG to stay so they can get the epidural, they don't care if that means they may need pit too.

Elvish, BSN, DNP, RN, NP · Jul 23, 2011

But I guess what I'm saying is that if a woman is having an effectual progressing labor pattern, reassuring fetal heart rate tracings (no late or excessive variable decels), she's not post-term, no PROM, no evidence of chorio, no Rh-isoimmunization, no pregnancy-induced HTN, etc., I think she should question an MD's advice to AROM or to induce/augment.

:yeah:

When I got to the hospital in labor with my daughter back in May, I was 3.5cm/90/-2. The doc wanted to AROM and I refused. I don't think he was happy, but he never really set foot in the door at that point, and my nurse also happened to be my friend and was more than happy to run interference for me. I progressed from 3.5 to 9 in 90 minutes without the first whiff of Pit, and at 9 I SROMed. My daughter didn't start to descend until I started pushing and had he ruptured me earlier, who knows where her cord would have been. Everything might have been hunky dory, it probably would've been, who knows, but all the same I'm glad I refused. And I'm glad my nurse backed me up on it.