So I recently went to a basic EFM course that had nurses from several local hospitals. I have not started on the floor at my hospital yet, but several other nurses who work at mine attended as well. During the class nurses that were from other hospitals were doing stuff on their L&D floor that the nurses say that we don't do on ours and I was wondering what is common/safe practice?
1. Urine screen on all new admits - most hospitals are doing this to rule out drug use for baby's safety. Our hospital doesn't.
2. Admistering Nubain - our instructor said that this drug is typically not used in L&D anymore as a nondisclosing drug abuser who gets this drug can go into withdrawal and have seizures. However, apparently at our hospital we are still giving it.
3. Ultrasound on new admits - other hospitals do this to rule out breech position on admission but ours doesn't.
4. Pitocin- a nurse from my hospital said she decreases rate by half instead of shutting off completely with late decels. Instructor said this wasn't safe practice and should stop it.
5. Cord Blood Gas - our hospital obtains this on all babies but some were saying that it is pointless and not cost effective?
Just had a baby a year ago. They did not check a urine drug screen upon admission or do an ultrasound for position. I consider it a good hospital (I work there, just not in L&D).
1. Hopefully they're getting a consent before collecting the UDS, and if not, they're not reporting the result to CPS or law enforcement, which would be in violation of federal law. No, we do not do a UDS on all women, only in specific predetermined situations that are guided by official policy (e.g. no prenatal care, history of drug use, presentation with abruption or uterine rupture, etc).
2. We haven't given Nubain in labor in YEARS. Fentanyl is the IV drug of choice for labor analgesia.
3. No. The only time we require U/S on admit is for inductions of labor where there is no provider documentation of presentation within the last 24 hours. Other than that scenario, we rely on the nurse/provider's assessment skill during SVE.
4. If you are changing the Pit rate due to NRFHTs, it's not legally defensible to decrease it. The only defensible action is to shut it off. The only time it's appropriate to simply decrease the Pit rate is if it's due to tachysystole.
5. IMO it is pointless and not cost effective. The only time we do cord gases is for low Apgars or other signs of fetal distress at time of delivery.
ETA: Isn't it fascinating to see how other facilities practice??
1. Urine screen on all new admits - We get a urine sample on all admits, but set it aside and only send it for a UDS if pt is a known drug user, had no prenatal care, had spotty prenatal care, or we are suspicious for some reason (track marks, etc). We also sometimes use it for pre-eclamptic labs or a UA if we suspect UTI, so we aren't just making them pee for a UDS.
2. Admistering Nubain - We mostly give stadol. We have 2 physicians that sometimes give nubain in labor. We do give nubain after c-sections for itching r/t the duramorph.
3. Ultrasound on new admits - Definitely not on every patient. If they have no prenatal care (ie, no previous scans), are known to have an unstable lie, we are getting heart tones up high, we think we feel a butt or feet during cervical check or suspect breech via leopolds we will do a scan.
4. Pitocin- We do what the physician orders. If no physician is around and I am having a major decel, I will shut it off and ask questions later. If they are having subtle lates, I will discuss it with the physician. Sometimes they want it off, sometimes they want to decrease it and reasses in 30 mins.
5. Cord Blood Gas - We get it on all babies. No idea on it's cost effectiveness.
1. Urine screen: We ask for a urine sample from any patient coming in through our OBED. We don't always send it, but when we do it's usually to check for a UTI. We have a protocol in place for UDS and it is not universal.
2. Nubain: We do not use Nubain. We use Stadol, I hate it. Like Klone said, I prefer Fentanyl, you can give the patient some actual relief and the half-life is WAY, WAY shorter (4 hours vs 18 for Stadol).
3. Ultrasound: Our OBED providers will often do a quick bedside look for presentation, but it is not a formal ultrasound. We have a lot of patients with limited or no prenatal care so knowing this information is quite helpful.
4. Pitocin: 100% agree with Klone on this. Decrease is for tachysystole, discontinue for distress.
5. Cord gas: This is not necessary and not recommended by evidence for use at every delivery. It's expensive as well.
UDS: It's a default on our EHR screen, but most of the providers will uncheck it unless there's an abruption, no PNC, or a history of drug use.
Nubain: Haven't seen it in a very long time. Not only is it bad for withdrawal, our newborns would forget to breathe for several hours post birth.
U/S on admit: Only there's a hx unstable lie or prior u/s was breech. (we're a teaching hospital, so sometimes residents aren't always sure what they're feeling, or need practice with the U/S so they'll do it in that case, but by no means everyone.)
Pit: It goes off completely with late decels. Late decels = uteroplacental insufficiency. Baby needs a break, as do uterine receptors.
Cord gases: Only if there was a bad strip and/or an unexpected NICU admit. My thing is, if you're not going to do anything with the information, why run it just because?
1. At my hospital we do an UDS on all OB admission. Our state law requires assent, not consent. With the increase in opioid addiction, we find MANY positives on patients you would never guess. The neonates then withdraw in the hospital under care, rather than being sent home immediately.
2. Our drug of choice for labor is stadol. We have not used Nubian in years.
3. We perform bedside ultrasounds on all inductions, and all service patients in labor. Our private attending pts do not get ultrasounds unless the triage nurse was unable to confirm vertex presentation with the initial vaginal exam.
4.If you have a non reassuring fetal heart tracing, pitocin should be discontinued. If you are decreasing pitocin due to tachysystole, pitocin may be halved instead of turning off.
5. IMO doing a cord blood gas is not cost effective in this day of bundled care/pay. We have protocols to draw cord gasses ie: apgars less than 5, assisted deliveries, stat c/s due to NRFHR.
Quote from maberRN
Our state law requires assent, not consent. .
What does that mean?
If a woman tests positive for opiates, do you do anything with that information, such as call CPS or notify anyone else outside the woman's/infant's care provider? If so, you are violating federal law if you're not first obtaining INFORMED consent, irrespective of what your state mandates (see US Supreme Court decision Ferguson v. City of Charleston). If you are JUST using the result to inform medical care, that's different.
1. Urine screen on all new admits
My hospital does a UDS on patients that were late to prenatal care, had no prenatal care, or admitted to drug use during pregnancy. We are required to get a consent by the patient before obtaining it.
We do, however, get a urine on our admits to make sure their urine looks okay. We do a basic UA on everyone unless they're ruptured.
2. Admistering Nubain
We do not give nubain on our floor. We use IV fentanyl or IM morphine & phenergan.
3. Ultrasound on new admits
We do not do this with everyone unless there is suspicion of breech or transverse presentation.
We shut the Pitocin off with late decels. We also do not give oxygen with Pitocin running if the baby is in distress.
5. Cord blood gases
We only get these when the doctor asks for it; decels or shoulder dystocia, typically.
Must Read Topics