My 2 cents on natural birth/birth plans

[feebebe23]

I am a new poster here and I have read a lot of debates on birth plans....controling dads....refusing this refusing/that ect....so here is my 2 cents.

When presented with a 14+ page birth plan I politely expain that "this is a hospital and not a jail" you have the right to refuse and and all procedures/interventions ect.

For example...That the hospital's policy is that you only eat ice chips during labor . However I can not stop you from physically drinking fluids and eating, I can only inform you of the hospitals policy and rational. If you choose to not comply with this policy that is your choice and I will need to sign this AMA form that states you have choosen not to comply with the doctors orders.

This speech can be altered to fit any request.....this is all done very politly and with professionalism....

I inform the pt/couple that her health and safety and that of her baby's is the hospital's number one priorty. I inform the patient that refusing to comply with hospital policy does not change the "excellent level of care that she and her baby will receive" It only minimalizes the risk of liability to myself and the hospital. (which may or not be true depending on the circumstances)

For example.....having a patient refuse continious monitoring....I once had a patient sign an AMA form in which I wrote...

I_________ am declining continious monitoring. I have agreed to intermittent monitoring in accordance with AWWON guideline. I understand that in some circumstances my baby's heart rate may increase or decrease and go undected for 5-30 minutes depending on my stage of labor. I am aware that these changes could result in the injury or death of my baby.

I have done this on more that one ocassion....place a sticker on the form....witness it...and put it in the chart. My managers are aware of this and have never commented....I have had 1 doctor thank me and say....good thinking!! I have no idea if this would be legaling binding or not. But something is better that nothing....

I addition to the "do not offer me pain meds" or my personal favorite...."my husband/coach and I have a secret code...he will let you know if I decide to get an epidural"

I states the following...

"I am leagally obligated to inform you that you have IV pain meds and an epidural avaliable to you, and after this conversation I won't bring up the E word again unless you bring it up first....IF at any time you ask for an epidual we will change positions, take a trip to the BR...or just take a moment to regroup. Then if you ask for an epidural again in 15 minutes I will make that happen. The rules are....you have to ask for it twice 15 minutes apart"

I have always had this agreement welcomed!! I have been thanked...send cards, flowers, and letters saying from patients "That nurse supported my decision to go natural"

These are just some tips I have developed through the years...

[eden]

It is scare tatctic when you say "if you don't have EFM your baby's HR can go down but may not be dectected for 5-30 minutes".

The reality is that most labors and deliveries are uneventful and that evidence based practice shows that IA is comprable to EFM in outcomes, with fewer unnecessary c-sections. Just because it's policy to have EFM does not mean it should be the golden standard, especially when evidence based practice says otherwise an AWHONN backs up said evidence with studies.

The really bad outcomes are often the ones where you least expect them and even when everything is in place as it should be, it does not change the outcome and nothing more could have been done. There was a case study of a severe dystocia with apgars of 0/0/1/4/7 where it was unexpected and everything and everyone was in place. Nothing more could have been done and baby is doing super now but even when the outcome didnot look so favorable there was never any talk of litigation because everything that could have been done, was done. No IV or EFM could have predicted this or changed the outcome.

[tvccrn, ASN, RN]

It is scare tatctic when you say "if you don't have EFM your baby's HR can go down but may not be dectected for 5-30 minutes".

I don't think that's a scare tactic. It's simply stating the facts. If she had added"...and by that time your baby could be dead." THAT would have made it a scre tactic.

tvccrn

[eden]

It's not stating the facts because evidence suggests otherwise. Why not tell them that EFM is subject to misinterpretation, is subjective (2 people can interpret the same strip differently) and there is evidence that IA is just as good, in terms of outcomes?

[feebebe23]

My comment to EDEN.....

I completely agree with you. I know that there is not evidence based practice that states continious efm decreased bad outcomes. I know this.....but have you ever seen a totally normal, term, spont. labor, no pit, no nothing baby crash down to the 60s for no reason....cuz I have. And no it usually doesn't cause a bad outcome when you flip mom over give a little O2 and the baby recovers.

This is a story from a friend....at a different hospital.....mom is in early labor 3cm....asks if she can walk around....good nurse says of course you can....nurse says "if your ctx get stronger or your water breaks come right back....mom and dad go walking....down the elevator....outside....moms water breaks.....she nice and slowly returns back inside....up the elevator....back to L&D....where she is placed on the monitor...FHTs 40-50...prolapsed cord.....you get the idea...

My point is while your on my unit and I am your nurse.....your my responsibility.....and I agree that a lot of interventions are unnessary.

When you (the patient) starts calling all the shots ie I won't wear the monitors, I won't have an IV.....you start taking away my ability to assess and insure your safety....

I am all for natural birth....bradley birth....but be reasonable about what your asking your nurse/hospital to do for you....have a hep lock....politely tell your doctor that you would perfer not to have your membranes artificially ruptures....with my naturals I always let them know...you are not strapped to the bed....you have 8 feet of monitor cord to work with.....stand up....sit in the rocking chair....get on the birthing ball....and I always tell my naturals that they are free to unplug and go to the BR when ever they would like, and I offer this at least 1X/hr....its OK to say to your doctor/nurse "I do not feel an urge to push, and I would perfer to not be checked at this time"

You catch more flys with honey.....and that goes both ways in the nurse/patient relationship.

[NPinWCH]

Feebebe23, I understand what you are saying...I empathize with you entirely, but I don't agree with you.

I've done L&D for 12 years and I've seen some really wacky stuff in those 12 years. I think we've all seen babies doing fine, laboring along, no pit just suddenly drop their FHR into the 60s for no reason. I've also seen babies with FHRs looking great on the monitor have uncomplicated deliveries suddenly come out limp and blue.

My problem with constant FM is that every study shows that it doesn't improve outcomes, only increases interventions when compared with IA.

When I was pregnant with my first child I was undergoing a "routine" 2nd trimester ultrasound. The doc was scanning the heart when it just stopped. I don't mean slowed down, I mean as we were watching his heart stopped! It was only for about 10-15 sec, but it wasn't beating then suddenly it started back up slow at first then up to a normal rate.

OK, so I was near hysterical...there was obviously something wrong with my baby. Test, after test after test showed nothing. I was terrified if I didn't feel him move for an hour or so...a few months later he came out screaming his head off without any problems.

My point? Well, if I had been in the hospital and in labor and that would have happened I would have had tons of interventions and maybe ended up with an emergency C/S...the outcome wouldn't have been any different. If we began EFM on every baby starting at 26 weeks we would be delivering a whole lot more babies early based entirely on an EFM strip.

We usually do continual FM, most pts get epidurals, but we don't have centralized monitoring where I work, so if something shows up and I'm busy with another pt or helping in another delivery and don't get back into the pts room for 15 minutes the FHR can be down for that entire time. Personally I would rather use IA than to have a "crappy strip" x 15min and nothing being done about it! Which one looks worse in court???

[HappyNurse2005, RN]

I don't think that's a scare tactic. It's simply stating the facts. If she had added"...and by that time your baby could be dead." THAT would have made it a scre tactic.

tvccrn

but she did say that, in the OP. to quote hte OP:

I understand that in some circumstances my baby's heart rate may increase or decrease and go undected for 5-30 minutes depending on my stage of labor. I am aware that these changes could result in the injury or death of my baby.

[eden]

Yes I have seen an unexpected twist or 2 where the FHR suddenly decreases but there is usually a reason( quick descent, quick progress in labor, nuchal cord ect). I have also seen babies on the monitor who look beautiful come out needing resusitation.

Asking for IA or refusing a heplock does not limit my ablitity to assess a woman or her baby. At my facility there are not mandatory IV's and I have never had a problem getting access when needed.

I also find that even while on the monitor, yes you can sit/be on hands and knees ect but it can be difficult to pick the baby in those positions. Alot of the time mom's HR comes in stronger and the monitor picks up her HR so what good is EFM when you end up monitoring mom instead? I can easily do IA in the tub/shower/hands and knees or on the ball and be confident in what I'm hearing vs having a baby with a basline of 120 and a tachy mom whose HR is 130 and not know who I am seeing.

I'm not saying EFM does not have a place in L&D ( it can be very useful) but it does not have to be an all or nothing type of monitoring situation.

[feebebe23]

I could not imagin not having central monitoring....ahhhh

And I agree sometimes you do pick up mom not baby with a mom moving around alot.

And yes.....babies decel all the time when no one is looking....as in the entire pregnancy...babies roll on their cords....so i agree with what your saying.....so here's the questions.

mom comes in....a bradley mom....she's 3 cm....having regular ctx....appears umcomfortable/early labor....she would like intermittent monitoring...for me FHTs q30 min means I get 5 min strip every 25 min...making sure before/during/after ctx....so getting an etire 5 min....hey thats just me.....so 25 min has gone by....you go in fhts 60's...how long has baby been down 2 min or 10?....you do all your stuff...call MD/IV bolus/position/O2...minutes go by....off to the OR...baby out well before the 30 min to incision.

All things be equal.....do they have a case? In your opinion?

[feebebe23]

RNINWCH....

I agree with you...If I did not have central monitoring....I would not put someone on cont. efm unless necessary.....and then they should be 1to1....for the reason you stated....

I work at a very busy....very hmmmm how shall we say this "upscale" hospial and surrounding area....

We could not function w/o central monitoring.

And let me tell ya....where I work......avoiding litigation is the #1 priorty.....so some of my opinions may differ from someone with different work experiences.

[NPinWCH]

I could not imagin not having central monitoring....ahhhh

And I agree sometimes you do pick up mom not baby with a mom moving around alot.

And yes.....babies decel all the time when no one is looking....as in the entire pregnancy...babies roll on their cords....so i agree with what your saying.....so here's the questions.

mom comes in....a bradley mom....she's 3 cm....having regular ctx....appears umcomfortable/early labor....she would like intermittent monitoring...for me FHTs q30 min means I get 5 min strip every 25 min...making sure before/during/after ctx....so getting an etire 5 min....hey thats just me.....so 25 min has gone by....you go in fhts 60's...how long has baby been down 2 min or 10?....you do all your stuff...call MD/IV bolus/position/O2...minutes go by....off to the OR...baby out well before the 30 min to incision.

All things be equal.....do they have a case? In your opinion?

Well...some people are going to sue regardless of the why, and some are going to win. Many times a jury gives a pt big $$ based on emotion...so it doesn't matter what you do.

I'm going to assume that there is a bad outcome, otherwise you wouldn't pose this question. So it comes down to:

1. Did you follow hospital procedure? If hospital procedure doesn't allow for IA, then it really should be changed, since anytime you don't use continuous EFM you are violating hospital policy, which is going to look bad. (Our policy for healthy mom in routine labor is NST, if reactive pt may be intermittent monitored following the awhonn guidelines. If anything is funky with IA then a minimum of a 30 min strip is run. If that is OK then we can go back to IA if desired.

2. Does that procedure follow the normal standard of care? It won't matter if you followed a policy that is wrong.

We used to use rice socks for back pain..had a policy in place, pts loved them. Well one day a well meaning, but not exactly bright nurse allowed an epiduralized pt to use one. Pt ended up with a 2x3cm blister/burn just above her tailbone, we put abx ointment on it. Pt didn't follow up at 6 wks, but chose to sue when baby was 4 months old for loss of intimacy with her husband because she was ashamed of the scar...our policy didn't actually state not to use the heated rice sock on pts with numbness/epidurals so case settled for $90,000 out of court.

3. Did you follow doctors orders? If doctor orders the treatment/intervention, you don't do it because pt doesn't want it and you don't tell the doc...you are setting yourself up for trouble.

4. Did the dr's orders follow the normal standard of care? Of course if the order is wrong or dangerous then you should refuse...we have all seen those types of stories...

5. Were the options explained to the parents, did they understand the risk vs benefit? Everything we do has a risk as well as a benefit. The prn loc I put in gives me immediate venous access in an emergency, but introduces the risk of infection, allergy...

That EFM gives me a better idea whats going on, but it limits my pts mobility which increases discomfort increasing the need for pain meds as well as slowing labor. Not moving makes it more likely that cord compression will occur increasing the chance of distress, which makes it more likely that more interventions will be used. Every time I intervene I increase the risks...now I'm not saying hospitals are bad places to give birth BUT I am saying that alot of what we do is completly based on "what we've always done" and faulty reasoning and bad science.

[Belinda-wales, RN]

What a hot topic- Many of you know that I am a nurse midwife from the uk where all women recieve care from midwife and if high risk doctor as well- only high risk moms have IV and cont montioring- the care is research based and very safe. I now work a a clinical manager with in L&d and things are different here- usally the justification is litigations but no worries people sue inthe UKjust as much if the out is poor. I have a lot of admiration for the nurses I work with I think that they do a really great job under sometimes very stressful circumstands-I am very confident letting the clients take charge of there own birth and with good comunication it can work well for all - every nurse that works on l&d in the uk is a trained midwife so that helps with confidence the course is 18 months long full time this long with nursing course which is three years full time equals nearly five years of education -we have nurses on our unit who do there nursing in 16 months and then 12 weeks orentation are left to look after a labouring family- I think they do a great job- it would benifit L&D nursing if a national course for L&D nurses was offered to all.

[eden]

rninwhc got to the reply before I could but said everything I would have.

I use both EFM and IA readily in practice, depending on the situation. I just don't think that someone not agreeing to EFM, if an initial 30 minute strip is reactive, is being unreasonable.