Why do we need the docs for delivery?

BENNETTRN · May 11, 2005

Shoulder dystocias seem to frighten everyone. However, there are ways to educate yourself so you at least have a clue as to how to handle the problem. I figure that if something scares the piss out of ya, it's worth researching a little so it doesn't scare you as much. :)
I was always taught (in case, God forbid, a mother gave birth precipitously at home while I attended her as a doula) that you can do the Gaskin maneuver. You simply flip mom into an all fours position and this can unstick the baby (and in my case, while simultaneously dialing 911 and popping a Xanax :) ). The maneuver was popularized by Ina May Gaskin, a lay midwife and author of Spiritual Midwifery. At her birth center on The Farm, in Tennesee, they have something like a 2% c-section rate, and they do breech births and twin births. Incredible stuff. Anyway, she learned the maneuver from midwives overseas, and she trains other midwives and docs in this procedure. It's slowly catching on and appears to be highly effective in preventing both maternal and fetal complications.
The more standard one is McRoberts, which I've seen a couple of times, though you can really hurt a woman if you overextend her, so you have to be careful. If the mom is unmedicated or has a light epidural in, the Gaskin maneuver is certainly worth a try, and even women with heavier epidurals can potentially be flipped over. Any of the experienced L&D nurses have familiarity with this?
A doula friend of mine was laboring at a birth center with a client in the middle of the night, the doc and assistant had been called, but mom was speeding along. As the baby was coming out, shoulder dystocia happened. So DeeDee, who deserves the Doula of the Year Award for keeping her head on straight, flipped mom into the Gaskin maneuver. And waited for a moment. And nothing. She then had to corkscrew the baby out, which worked fine. In fact, she had seen a similar case the week before when she assisted at a homebirth with a CNM. The CNM showed her exactly what to do in such a case.
The point is that the docs aren't the only ones who hold the secret info about shoulder dystocia. Traditional midwives, CNM's and others have passed down great wisdom as well through the ages.
Here's a good article, with accompanying research, on the Gaskin Maneuver - the first obstetrical maneuver to be named after a midwife:
http://www.inamay.com/gaskin_maneuver.php
Alison

Hello FrumDoula- It sure is funny you say to educate yourself on something that scares you so, because 2 weeks ago I took a 2 CEU/CNE shoulder dystocia class, and I have to tell I was more scared when I walked out of that class than I was before I went! First, I work at a hospital where 99% of all our pts have epidurals, and they are of a how would you say it a "upper class group" of pts who expect nothing less than their birth plan to be followed to the tee, and nothing less than a PERFECT outcome. I am well aware of the manuevers,(McRoberts, Rubins, Woods screw, Delivery of posterior arm, SP pressure in oblique orientation, and God forbid Zavanelli's) and have been in one serious dystocia of my own and assisted 2 other nurses births with dystocia's. You have approx 4 min's to deliver the body, so with a epidural, getting the pt on all fours will take at least half of your time, and if it doesnt work you dont have much time left. Brachial plexus injuries are the 2nd leading cause of obstetric lawsuit!!!!! Then you run such a high risk of large perineal lac's, including 4th degree, cervical lac's, and pp hemmorrhage, all of which you need the doc there to take care of. So for those of us trying to avoid injury to our pts (mom and baby), and lawsuits we need the doc there. The dystocia's I have been in, the mother and fetus had no risk factors of dystocia, so as you know, you may have a comp on your hands that you have 4 min's to deal with, and it can take the doc well over that to get there, or any "OB in the house" for that matter to arrive. Knowledge is power!!!! but in some cases all of the above doesnt work, and I have to have the doc there for the next step. By the way our unit just recently had a pt in which the Zavanelli maneuver was preformed and section was done with a good outcome (uggggggggggggHHHHHHHH)!!!!!!!!

But its a reminder it can happen anytime without warning and it is out of the regular RN's scope to perform many of the interventions!!!!!!!!!

BENNETTRN · May 11, 2005

A-men. Thank goodness this is not too common.

I second that!

FrumDoula · May 11, 2005

The old knee chest maneuver you speak of does NOT always unstick a baby....Attend a few of these deliveries when the doc has to break the clavicle...You will never forget it...

Are you talking about McRoberts or the Gaskin maneuver? I'm a little unclear ....

Alison

sbic56, BSN, RN · May 11, 2005

Hello FrumDoula- It sure is funny you say to educate yourself on something that scares you so, because 2 weeks ago I took a 2 CEU/CNE shoulder dystocia class, and I have to tell I was more scared when I walked out of that class than I was before I went! First, I work at a hospital where 99% of all our pts have epidurals, and they are of a how would you say it a "upper class group" of pts who expect nothing less than their birth plan to be followed to the tee, and nothing less than a PERFECT outcome. I am well aware of the manuevers,(McRoberts, Rubins, Woods screw, Delivery of posterior arm, SP pressure in oblique orientation, and God forbid Zavanelli's) and have been in one serious dystocia of my own and assisted 2 other nurses births with dystocia's. You have approx 4 min's to deliver the body, so with a epidural, getting the pt on all fours will take at least half of your time, and if it doesnt work you dont have much time left. Brachial plexus injuries are the 2nd leading cause of obstetric lawsuit!!!!! Then you run such a high risk of large perineal lac's, including 4th degree, cervical lac's, and pp hemmorrhage, all of which you need the doc there to take care of. So for those of us trying to avoid injury to our pts (mom and baby), and lawsuits we need the doc there. The dystocia's I have been in, the mother and fetus had no risk factors of dystocia, so as you know, you may have a comp on your hands that you have 4 min's to deal with, and it can take the doc well over that to get there, or any "OB in the house" for that matter to arrive. Knowledge is power!!!! but in some cases all of the above doesnt work, and I have to have the doc there for the next step. By the way our unit just recently had a pt in which the Zavanelli maneuver was preformed and section was done with a good outcome (uggggggggggggHHHHHHHH)!!!!!!!!
But its a reminder it can happen anytime without warning and it is out of the regular RN's scope to perform many of the interventions!!!!!!!!!

Great reply. I feel the same way about it all!

SmilingBluEyes · May 11, 2005

The maneuver to move the baby back up the birth canal to facilitate csection (Zavanelli) is a REAL challenge. Just had to do that not long ago......Talk about difficult, esp for a short girl like me. I was glad that baby came out ok, thankfully. A skilled doctor made all the difference in that case---as the cardinal movements of the fetal descent must be reversed.

mitchsmom · May 11, 2005

Are you talking about McRoberts or the Gaskin maneuver? I'm a little unclear ....
Alison

knee to chest is McRoberts :)

SheaTab · May 12, 2005

steph>>>

Holy Cow!!! I have never had a doc sit with me and push for two hours. I am impressed with your physicians! We get dirty looks from our physicians if the baby is not about to fall out of the lady parts when they are called into the room. T.

mitchsmom · May 12, 2005

steph>>>
Holy Cow!!! I have never had a doc sit with me and push for two hours. I am impressed with your physicians! We get dirty looks from our physicians if the baby is not about to fall out of the lady parts when they are called into the room. T.

I have no professional experience, but my first two births the docs showed up with probably about 15 minutes to spare, the last one was there for about the last 30 minutes and she was a personal friend of mine at that! (She actually did stay at the hospital during most of the labor & would ck on me, but she went to do other work that she needed to do while I labored, which was ok w/ me. When I observed several births with her later, she also showed up at the last 15-30 minutes with them too. )

Guess I had the "fall out of the lady parts" type docs mentioned above for my births! LOL

SheaTab · May 13, 2005

I have no professional experience, but my first two births the docs showed up with probably about 15 minutes to spare, the last one was there for about the last 30 minutes and she was a personal friend of mine at that! (She actually did stay at the hospital during most of the labor & would ck on me, but she went to do other work that she needed to do while I labored, which was ok w/ me. When I observed several births with her later, she also showed up at the last 15-30 minutes with them too. )
Guess I had the "fall out of the lady parts" type docs mentioned above for my births! LOL

I plan on attending CNM school next year... I can definitively tell you that I will not be this way! ;o) The nurses won't be able to get me out of their room. I sometimes think though, the less the docs are in my room, the better. Because it seems like everytime they walk in they are messing with something! When do you plan on going to CNM school? Where? Email me privately if you'd like... [email protected]

Dayray, RN · May 27, 2005

I think Nurses opinions on this subject are largely dependent on what type of environment we work in.

Personally I have worked in both a small rural hospital (briefly) and a large busy high risk/ high volume hospital (currently).

Patents ask me this question from time to time I even had a family ask me not to call the doctor. "We really want you to do this".

My opinion is .. Well maybe I don't have an opinion but I do have some observations/ comments.

When I worked in the rural environment I depended much more heavily on the doctor. My small hospital didn't see much outside of the norm and the doctors were not nearly as busy so they provided much more personalized care and I saw allot less of "cut and silastic" then I have where I now work. In this environment the doctors training was very important and I would never dream of delivering babies.

Where I work now I see so many complications. When there is an emergency I don't wait for orders because I know what to do as well or better then the doctor. Instead we work as a team and most times we do that well. Doctors don't touch the babies I do that or if I anticipate a problem I call the NNP who is (although sometimes they forget) another nurse. At the hospital I work at we are on a first name basis with our docs and most of them see us as peers not as lackies.

That being said I really don't think that they are necessary at deliveries. There is no reason that a nurse couldn't catch a baby and call the doc in for C/S.

Now that being said I personally am happy that there are things (such as catching) that I don't have to do I like not having to do everything because I have to do so much and the thrill of catching babies has long past for me. I like taking care of my patient's allot more then just catching a baby.

Doctors do the prenatal screening and monitoring some do an excellent job educating their patents but sadly that is their weakest point.

As for medicine taking over childbearing I am conflicted on my opinion.

I work in a very busy hospital and have seen awful things happen to patents because doctors are rushed. It took me some time to become strong enough to stand up to them and keep them from cutting an apease using silatic or starting pit unnecessarily and I know that many of my coworkers will never be able to do this. For these reasons I think that some patients would greatly benefit from nurses doing deliveries. For one thing we are there for 12 hours weather they deliver or not. Doctors need to get in and out as quickly as possible, either to get back to the office, to sleep or to make it to their daughters dance recital. We all know how difficult their schedules can be and at some point the battle between work and home weighs on them.

This is a major problem with the medical system as it is now. They really have to choose between their family and their work on a daily basis. Another aspect of this is that as nurses we get to know the patient more closely then they do. We are there with them for hours where as most of the time docs only see them briefly at visits and for a few minutes at delivery. It's a lot harder for us to forget that this is not only a patient but also a mother/wife/daughter/human being.

On the other hand medicine (when I say medicine I mean the discipline not meds) has done so much for women and babies. Many, many women and children died before hospital birth was the norm. We currently live in a time when death in childbirth for mother or baby is pretty rare and that is because of medicine.

In many cases it would actually make my job easier to just do the delivery and I think it would in many cases be better for the patients. Yet if this were to happen care might suffer because you would then need 2 nurses at a delivery and I'm sure we wouldn't be staffed any better.

Really the real answer to the question "why do we need doctors at deliveries?" is: because that is what people expect.

Think about the first time parents who ask, "when is my doctor coming" or walk in and say. "yes I am supposed to meet my doctor here to be checked" ...lol

People believe that doctors are THE care provider. Back when I worked med surge I took care of a man for 3 weeks and eventually was part of a very long Code on him. We worked and worked and finally got a pulse back. The next day his wife came in and tanked the doctor (who wasn't even at the code) for saving his life.

The public's perception of doctors as superior life form has been molded by television and in no small part by the AMA and I don't see it changing soon.

Jolie, BSN · May 27, 2005

Whew, Dayray! Where have you been? I've missed your posts!

Dayray, RN · May 28, 2005

Whew, Dayray! Where have you been? I've missed your posts!

Hi Jolie =)

It was a busy semester for my wife so was takeing up allot of the slack with household/ family stuff and was on a major reading binge. I did stop in from time to time but just did'nt post. My wife is out of school for a while and I ran out of books I wanted to read so ill prolly hang around for awhile.