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...
Here's the thing: scare tactic or not, this is NOT true. Research has shown, and AWHONN teaches in the intermediate fetal monitoring class, that outcomes are no worse with IA than with CEFM. So there is no greater risk of death or injury to the baby than there is with CEFM. What there is a greater risk of with CEFM is unnecesary intervention including c-section and the greater morbidity/mortality that comes with all those interventions. Do you tell your patients that?
There is NO difference in outcomes between IA and CEFM and call it whatever you want, but telling patients anything other than the truth about it is lying. Telling them the relative risks and benefits of each method and allowing them to choice without "playing the dead baby card" to sway them towards what you want would be a much better option.
In the grand scheme of things, with statistics drawn from millions of deliveries world-wide, there probably is no difference in outcomes of deliveries monitored by EFM vs. IA. But we all know that there ARE times when the fetal heartrate pattern is concerning and warrants very close "observation" that can not be provided by IA. My second baby's occult prolapsed cord would be a shining example of such a circumstance. Had I refused continuous monitoring when the nurse detected a problem (in favor of IA every 30 minutes) my daughter would have been dead.
Likewise, I will agree that there are times when strapping a laboring mom to a monitor is unnecessary and counterproductive.
In the grand scheme of things, with statistics drawn from millions of deliveries world-wide, there probably is no difference in outcomes of deliveries monitored by EFM vs. IA. But we all know that there ARE times when the fetal heartrate pattern is concerning and warrants very close "observation" that can not be provided by IA. My second baby's occult prolapsed cord would be a shining example of such a circumstance. Had I refused continuous monitoring when the nurse detected a problem (in favor of IA every 30 minutes) my daughter would have been dead.
Likewise, I will agree that there are times when strapping a laboring mom to a monitor is unnecessary and counterproductive.
Exactly! IA picked up the problem and alerted you to the fact that closer monitoring was required. IA was effective at detecting the issue and the problem was effectively dealt with. At the point when a problem was detected with IA and the nurse was advocating for CEFM to further evaluate it would have been appropriate to say that IA could be detrimental to the baby. Not before there was a problem.
I dealt with this in my own labor as well when IA detected fetal tachycardia. With CEFM for 45 minutes or so the HR returned to normal and we went back to IA. I had no problem with EFM when there was reason for concern.
Specializes in postpartum, nursery, high risk L&D.
Really enjoy reading about others experience with birth plans. I think it all depends on the community you are working in. I would welcome a patient thinking ahead enough to ask for natural birth or having a birthing plan. Most of the women I see have one plan, "give me an epidural as soon as possible and induce me now because I am tired of being pregnant. Would like to see the mother worry about what is best for the baby and not what is comfortable for her.
That is exactly how I feel; I jump at the chance to work with someone with a thought-out birth plan and/or wanting a natural birth, because most of the women I take care of have the same plan you describe.
Even before I was a nursing student I became a mom p- twice. Also being an academic, I looked up for myself about this fetal monitor debate. I went with the old fashioned IA. The nurses never gave me a problem, although a new nurse was pretty peeved, esp. when I refused to comply with "the hat".
I lot of practices for low risk labors are not based on science. I think we are slowly changing that and L&D nursing will change.
I loved my births, but I also had a doctor standing up for me was well as the nurses.
Really enjoy reading about others experience with birth plans. I think it all depends on the community you are working in. I would welcome a patient thinking ahead enough to ask for natural birth or having a birthing plan. Most of the women I see have one plan, "give me an epidural as soon as possible and induce me now because I am tired of being pregnant. Would like to see the mother worry about what is best for the baby and not what is comfortable for her.
That is exactly how I feel; I jump at the chance to work with someone with a thought-out birth plan and/or wanting a natural birth, because most of the women I take care of have the same plan you describe.
I agree with both of you. As nurses, we should be happy to support our patients in the decisions they make-- especially when the decisions they make are actually better for them and their baby! I mean-- thats a no brainer! We should be excited someone doesn't want an epidural because epidurals add risk. I think in OB sometimes we forget that we are supposed to be PATIENT ADVOCATES, not doctor, hospital, policy advocates-- yes we have to work within those constrants, but our ultimate responsibilty is to our patients.
It is too bad that the birth process has become so technical and complicated. I had my second child at home with a nurse midwife and it was a wonderful experience. And women who come to the hospital in labor always seem to do better that those that come in for inductions. Inductions, use of Pitocin, epidurals - all seem to contribute to the complications that moms experience in labor. If only we could all be more willing to let nature take its course!
It is too bad that the birth process has become so technical and complicated. I had my second child at home with a nurse midwife and it was a wonderful experience. And women who come to the hospital in labor always seem to do better that those that come in for inductions. Inductions, use of Pitocin, epidurals - all seem to contribute to the complications that moms experience in labor. If only we could all be more willing to let nature take its course!
ITA! The pit/narcotics/epidural landed me in the operating room for my first birth. As a result, I was determined to have a completely natural delivery the second time. I still wonder what my nurse for my second dd's delivery thought when I arrived at 2am during her shift. She left at 7am and when she returned at 7pm that night, I was still laboring.... without any drugs. :)
I wish I could have had a homebirth since I didn't want to deal with hospital protocols but finding a provider to attend a HBAC is difficult in my state since it's illegal for them.
I'm not sure why women need to come to the hospital with pages of birth plans. I toured the hospital to find out their policies and then questioned my provider to find out her policies. If you are going to take the time to develop a birth plan, why wouldn't you take the time to understand the way the hospital you plan to birth at operates? (This is a rhetorical question, obviously!) I gave my birth plan to my provider and doula so that they knew my wishes. I had a 1 page "abridged" birth plan for the hospital. I guess it went over okay since my nurse didn't make a big deal about it (and adhered to all my requests).
Regarding CFM - I was adamant about NOT having it at first since I knew I would need freedom to move around in order to have the natural delivery I desired. However, the hospital had wireless monitoring. Don't more hospitals have that? Several of the hospitals in my area offer telemetry. I was even able to use them in the laboring tub. It seemed like a good compromise.
This is EXACTLY why I will never work L&D. As a childbirth educator and labor support doula (in a pre-rn life), I cannot put myself in a situation where birth is treated like a scary thing. It makes my stomach turn.
Febebe23, I'm not saying there is anything wrong with you, it's bigger than any one RN. The entire business of birthing is off. Maternity care in this country is full of fear, scare tactics, and practices that are not evidenced based.
How would we feel if a cardiothoracic or neuro surgeon routinely practiced a procedure against every single piece or evidence out there? would we stand by and allow that person to practice? I don't think so, yet we take it and allow it when it comes to birth. Insane! in my humble opinion.
peace.
Quote: "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 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 would think the hospital would have a problem with their documents being amended by a nurse or any medical staff in this way. Your written additions might not be 100% accurate or medically factual. If the hospital wanted these comments in their docs chances are they would have included them.
I am a student right now, but as someone who has worked in compliance over the years altering docs is a big no-no. I understand why you are doing it, and I do admire your attempt to do something to protect yourself and the hospital. I fear however it could possibly have an adverse effect should something go wrong.
Have you talked to your the Legal Dept. or Risk Management team about the changes you make?! I would. If they concur then you are in the clear. I would hate to see you penalized should something go wrong when your intentions are honorable. I fear that while trying to minimize your liabilty you might actually being increasing it in the event of a tragedy.
Since I originally wrote this first post I have since switched hospitals. The new hospital that I work at actually has a preprinted refusal form for patient's refusing cont EFM!! Yeah!!
Ok...so if your hospital has a policy stating that ALL VBACS must have epidural catheters in place (not on pump...just in place) and must have internals....how do you document when patients come in a refuse them??
We ALL KNOW....if you are not following hospital written protocol you are putting your A$$ on the line....but I am not about to force/persuade someone who would like a natural VBAC to have these things..but you have to document that the patient is refusing to following hopital policy....
If patients want to dictate their own care....as they have the right to do...just dont blame me if something goes wrong....that's all I'm saying.
PS....we had a "natural patient" here recently....perfect strip....refused saline lock.....went to the BR for 30 min, came back to the monitors and the baby tanked!! took 12 minutes to get the IV in (finally in her foot) 12 minutes of terminal bradycardia in the 40s mind you...of course abruption....EEG is flat line. Apgars 1/0/0/1 Makes you wish she hadn't refused an IV....thank God I wasn't here when that happened....
As a nurse....I am jsut VERY CONCERNED with protecting myself!!
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...
Wonderful, wonderful, wonderful. You have a heart for birthing mothers.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I do that all the time. I explain options and treatments and tell them I am not a legalized drug pusher. If they choose to change the plan, all they need do is ask me. I will not discuss them (pain meds/epidurals) again, unless they or their family members/loved ones ask me to.
Jolie, BSN
6,375 Posts
In the grand scheme of things, with statistics drawn from millions of deliveries world-wide, there probably is no difference in outcomes of deliveries monitored by EFM vs. IA. But we all know that there ARE times when the fetal heartrate pattern is concerning and warrants very close "observation" that can not be provided by IA. My second baby's occult prolapsed cord would be a shining example of such a circumstance. Had I refused continuous monitoring when the nurse detected a problem (in favor of IA every 30 minutes) my daughter would have been dead.
Likewise, I will agree that there are times when strapping a laboring mom to a monitor is unnecessary and counterproductive.