Nurses role if Dr is not giving all options (VBAC specifically)

[maiday]

Hi!

I am in nursing school and writing a paper on ethical dilemma's in childbearing nursing. We are allowed to choose any topic as long as we can define the ethical dilemma and how it relates to BENEFICENCE, NONMALEFICENCE, JUSTICE and AUTONOMY. I have chosen to write my paper on VBACs. I believe it's an ethical dilemma considering how many hospitals will not even offer this as an option. I will be discussing VBAC in general, but my question is as a nurse, what would you consider your role to be if the Dr. you are working with does not do VBACs and is not giving your pt the full story. The Dr. is pushing the pt to have a repeat cesarean and not giving both sides of the story.

I chose this issue because it's personal to me and the above situation is not hypothetical except for the nurses role. I was pregnant after having my first child cesarean and the hospital my Dr. is affiliated with will not do VBACs. My Dr. did not even offer VBAC or tell me that might be an option, she assumed I would have a repeart c-section. I had to pry my options out of her and tell her flat out I wanted a VBAC. She tried to tell me that is was extremely risky and talk me out of it, but finally consented and said that at 36 wks my care would be transferred to a hospital an hour a way that would do VBACs.

Sorry for length. Also, I am not asking for opinions on VBACs, I've done my research there, but thanks. I'm just asking for what you would consider your role to be if the Dr. was not fully informing their pt.

Thanks!

[NurseNora, BSN, RN]

This has been worked out between the patient and her provider before she gets to the hospital and by then she is resigned to what will happen. I wouldn't ask a patient if she considered VBAC. The only way I'd get involved would be if the patient said something like, "I really don't want to do this, do I have to have a C/S?" Then I'd tell her that we can't do anything to her that she doesn't agree to. I'd tell the doc what she said and get him/her in to talk more with the patient. Even in that situation, I'm not sure I'd be the one to bring up VBAC. I'm not sure I wouldn't either, it would depend a lot on the circumstances.

My hospital doesn't offer VBACs because we don't have enough deliveries to offer 24/7 in house, dedicated OB anesthesia or OR staff and cannot guarantee getting a section going in 30min in case of emergency. We have done VBACs though. One doc has told some of his patients that if they stay home until they're in very active labor, they'll probably deliver before we can get a section set up. I don't know this to swear to in court, but I know in my heart that's what he sometimes does.

We have also had patients come in and refuse a repeat section. We then try to get them to fly out to a hospital that does do VBACs. If they still refuse, we have them sign an AMA form refusing a C/S and a transfer and be sure they know the risks of attempting a VBAC in our facility. The doc, anesthesia, and the OR crew then have to come in and stay in house until the patient delivers. If the patient doesn't use anesthesia or the OR, I don't think we can get reimbursed for that extra expense to the hospital.

[HappyNurse2005, RN]

My hospital doesn't offer VBACs because we don't have enough deliveries to offer 24/7 in house, dedicated OB anesthesia or OR staff and cannot guarantee getting a section going in 30min in case of emergency

now, nursenora, i know you didnt make this rule. so i am not insulting you when i say that this is the stupidest reason ever not to do a vbac. stupid stupid stupid.

if you can't guarantee that you can get a c/s going in 30 mins, you shouldn't be delivering babies at all. Prolapsed cords, severe fetal distress, placenta previa comes in bleeding like stink-you make them wait 30 mins??

[NurseNora, BSN, RN]

God takes good care of us. We're a rural hospital and it's a 3 hour flight to the nearest hospital where these things can be done rapidly.

Prolapsed cord? You get a real cramp in your hand holding the head up until everyone can get there. Distress? Recognize it early and intervene much earlier than we would have when I worked in a big city hospital. Previa bleeding? Knee chest until everyone is there. And in all those cases...Pray.

Making someone wait 30min? They wait until someone who can do the surgery shows up. We have done a few sections under local because anesthesia was tied up in the OR and it had to be done NOW. I was terrified when I first started working here because until then, all my experience was in large teaching hospitals. It was quite an adjustment. But, as I said, God takes good care of us which is a good thing, because even out here in the sticks women still insist on getting pregnant.

[maiday]

Not to get off subject and thank you for all replies... but that's usually the reason stated for not doing VBACs. Not saying it's a good reason, but in 1999 the ACOG stated that anesthesia and emergency c-section should be available if a hospital offered VBAC and since then, more and more hospitals have stopped offering VBACs. A chance of uterine rupture is only 1%, but hospitals don't want to be sued if that 1% happens in their hospital. But that's why I think it's an interesting topic. It's sort of a hot button right now since they just had the NIH conference specifically regarding VBACs. They recommended making VBACs a more viable option, but we'll see.

[BrnEyedGirl, BSN, MSN, RN, APRN]

I don't work L&D,..but I am often asked "if this was your daughter what would you do?",..etc. As an RN, it is my job to advise pt's and educate them,....very often the best advise I can give my pts is to ask questions. I tell them to write down questions to ask and keep asking until they get the answers they need and can understand. I try to empower my pts to play an active role in their health care and to become as educated as they can. I'm not above suggesting finding a new doc if that's what it takes. In your scenario,.I'm not sure I would ever tell a pt that it would be a better choice to have VBAC,.as in all honesty I probably wouldn't know,...but I could lead them to the answers to help them make their own decision.

[allig]

I see this happen frequently, patients getting either limited or absolutely false information about VBACs from their MDs. I work L&D at a high volume hospital (500 births/mo) where a handful of doctors and all the CNMS are very supportive of VBAC (and have a decent success rate). Other doctors, however are totally unsupportive. I've had women come in for a scheduled c-section, and I always ask her reason (non judgementally--I need to know if there's a medical indication-- is baby breech? previa? or an elective scheduled repeat?) I've heard responses such as "The doctor said once a c/s, always a c/s" or "I wanted to VBAC but s/he said only 10% are successful so why bother" to my favorite, "he said most VBAC babies die". Outright lies, and while it is not my place to give medical advice or personal opinion, I do feel it is my obligation to clarify misinformation; without addressing such misinformation, I ethically cannot let her sign the "informed consent" paperwork. I often just carry on with my admission process, and say something like, "Actually, other MDs do a lot of VBACs here, within certain criteria, and nationwide success rates are somewhere between 60-80%." Now if she says they discussed options and the

[dishes, BSN, RN]

allig

I am curious, what happens when the patient who is admitted for the c-section suddenly has doubts, how does the OB respond?

dishes

[klone, MSN, RN]

When the patient comes in for her scheduled C/S is not the time for me to be telling her she has other options, and why doesn't she try to VBAC?

[NurseNora, BSN, RN]

allig

I am curious, what happens when the patient who is admitted for the c-section suddenly has doubts, how does the OB respond?

dishes

It's very unusual for a pt scheduled for a C/S to arrive at the hospital expressing doubts about the procedure. After all, she has had since her original surgery to think about what happens next time. Even if she didn't think about "next time" for a while, she still has had the 9 months of her pregnancy to think about it and to seek information. By the time she gets to her date of scheduled surgery, she's usually just really glad the pregnancy is soon to be over.

That said, if someone did come in with doubts the nurse and the OB would try to find out where the doubts are coming from. What information does she have, what information does she need? Just what is the basis of the doubts and why are they arising only now and not during he last 9 months? If she suddenly insisted on VBAC, she would be offered a flight to the big city hospital where they do VBAC (if she were in labor), or given a referral to a physician in the city so she could make plans to deliver there. We cannot do a procedure on a patient without her consent. If the OB did not feel that he had the patient's consent, he wouldn't do the surgery. It's legally battery to touch someone who does not want to be touched.

[SmilingBluEyes]

Nora said it very well.

[CEG]

I struggled with this as an L & D nurse. I had a lot of patients who came in for induction at 39 weeks with no indication. When I asked them why they were being induced they didn't know or it was because it would be "dangerous" to be pregnant past her due date. As a patient advocate it was my job to educate my patient and be sure her needs were being met. It was also unethical practice on the part of the doctor to perform unnecessary procedures with risks to the patient for their own benefit. As an employee of the hospital who didn't want to get fired I had to walk a fine line. I did have a patient once who came in laboring and did not want to have a repeat c/s. I told her that was something she would have to discuss with the doc when he came in. I wasn't there for the conversation but she ended up having the c/s. I felt bad about taking the wimpy way out. The biggest problem in my eyes is that neither nurses nor patients can trust the doctors to do what is in the best interest of the patient.

Adding: a good way around this is to help your patient formulate questions to ask the doctor when they come in. Knowing the right questions to ask can help them get better info.

[melmarie23, MSN, RN]

I think its hard from your question to delineate where exactly the ethical dilemma lies. Hospitals have every right to choose not to perform VBACs. That isnt so much an ethical issue when the patient comes into the facility in labor because one could assume that this information was communicated to her before hand. If a VBAC was wanted, then the request to transfer care elsewhere should have been made.

Where I see an dilemma is when hospitals do provide this service and women are then not given a full trial of labor and end up sectioned anyways. I think you need to rephrase your problem statement a bit.

What then can a nurse do? Give as much continuous labor support as possible. Get her on her feet, have her walking around, have her sitting and rocking on a birthing ball, have her in the tub-anything and everything to try and get that baby down. And what I also think is needed is for the nurse to do her research and present and defend it to the necessary individuals and defend and help rewrite protocols that say that women can only push for X amount of hours before they whip her into the OR. But that is just my humble opinion.