I am curious about how other L&D nurses deal with an admitted primip, not ruptured , irregular uc's, not really progressing, but oh soooo in pain
( 1/th/high ), this being the reason for admit, and refusing pitocin ...and BTW, you only have 5 labor beds and are backed up with pts waiting for a bed. Now I am all for pt rights and stuff but....do you just babysit her or what ? too high for an "asrom" , of course, you could send her walking but she still officially has a bed....it can be very frustrating... And she has a right to decide how she wants to do it....do you give her a choice : you take the Pit or you hit the road ? well that would be rude, so how do you solve this ?
How do you suppose we could go about correcting the problem? Educate them about midwifery and home births? What are some options to allow them the slow (not always) natural births? I am asking because I truly want to know some ways to remedy the problem.
I do too....I guess ideally, this should be started before pregnancy but more realistically, in the doc's office...part of the initial prenatal care should be to educate the pt about the possible ways to do birthing...I guess if you're high risk at any point, well off you go to the hospital but other than that a midwife in a home or "alternative" environment would be great and certainly cheaper than the fast pace, production line of a hospital L&D I do believe we do too much intervening... low risk pts that want the natural way should probably not be in the hospital ( like a real birthing center close to a hospital, or home .with intermittent monitoring, heplock perhaps ) with midwives.
Also it never fails to amaze me how some pts come in with high unrealistic expectations ( birth plan and ball ) yet haven't got a clue...Has anyone possibly mentionned that pain might be involved here ? Or they are adamant about breastfeeding yet have not read 2 lines on it, do not have a clue about what to do....it's kinda sad really
Hmmm, at 1/thick/high we wouldn't even offer pitocin as it wouldn't likely be effective at that point, 'specially for a primip with membranes intact... if all checked out OK we'd offer to send her home with something for pain/sleep and stressing that if they were not effective she could return for therapeutic rest (usually morphine & phenergan IM; we keep them overnight when we give that since they sometimes wake up in active labor)
Now that our hospital has decided to follow Navigant's ($5 million consulting firm) recommendations regarding staffing, we are only allowed 48 nursing hours per delivery. This means that if we do 50 deliveries a week, we are allowed 2400 hours of paid nurses time per week, or 343 paid nursing hours a day, or 114 paid nursing hours per shift, or 15 nurses per shift for all of antepartum, l&d, triage, and postpartum. We really get screwed on the high risk antepartum patients that are with us for 2 months, as they require nursing care, but we are still only given 48 nursing hours to care for them during their stay. (We are supposed to "borrow" hours from other patients who do not require as much care). Triage patients, even though they require care and assessment, do not count in our staffing unless they deliver. If they go home, the hospital can send them a bill, but the hours to care for them has to be "borrowed" from another patient who maybe only stayed 24 hours. Confusing, and stupid as ****, but that is the brilliant minds of management.
We have a saying: Treat 'em and street 'em.
Even though the hospital can charge for each patient that walks through the door, we are only given a certain number of nurses in our budget. We simply do not have the staff to handle latent labor.
I'm all for supporting women's choices when it comes to their birth. That's why that woman should be offered pain control and then sent home. She doesn't need to be in the hospital at that point.
I agree. Not in labor. Go home to walk or rest or whatever.
We just did this last week - 2cm, posterior, thick . . shot of morphine and out the door. Had the baby two days later.
I am curious about how other L&D nurses deal with an admitted primip, not ruptured , irregular uc's, not really progressing, but oh soooo in pain
( 1/th/high ), this being the reason for admit, and refusing pitocin ...and BTW, you only have 5 labor beds and are backed up with pts waiting for a bed. Now I am all for pt rights and stuff but....do you just babysit her or what ? too high for an "asrom" , of course, you could send her walking but she still officially has a bed....it can be very frustrating... And she has a right to decide how she wants to do it....do you give her a choice : you take the Pit or you hit the road ? well that would be rude, so how do you solve this ?
Minou
You can solve that problem by NOT admitting those types of patients at all. We send them home as they are not in labor and shouldn't be there.
We often do "theraputic rest" on someone like that. After getting a reactive strip and assessing the situation, the patient is given something like Morphine and Phenergan (or one of the CNM's gives Morphine and Vistaril) IM and sent home to sleep. It either knocks the labor out or they return in a good labor pattern.
There is NO reason to start pit on the patient you have described above. I fully agree with that patient refusing pitocin.
I wish we could do that...once we give them the morphine, they are ours!
I agree with the gentle nudge out the door; they are often just not aware that this is not labor. They figure it out when the real thing comes, though! :wink2:
Why don't you do a little asking around. I think you would find out that many places medicate and send home. There is no sense monitoring a person you have medicated for sleep. When she sleeps (from meds) the baby sleeps as well.
I looks here as though many facilities medicate and send home.
Why don't you do a little asking around. I think you would find out that many places medicate and send home. There is no sense monitoring a person you have medicated for sleep. When she sleeps (from meds) the baby sleeps as well.
I looks here as though many facilities medicate and send home.
It might just be the small rural hospital mentality working here, plus theory is, it makes this anxious type of patient feel more comfortable and supported to be in the birthing center overnight. We don't monitor them, but the doc/midwife will see them in the a.m. and decisions made from there. I agree, morphine and a ride home sounds like a fine idea to me, but since it's done close to or at term and they may be miles from home, we opt to sleep them there in case labor really kicks in.
We outpt these gals and monitor, typically for 1-3 hours, for contractions and cervical change. If in pain, our obs will prescribe pain med. If no cervical change, or medical need, they are discharged. If they refuse induction, they are discharged. We are a small rural hospital and do not have the rooms or the nursing staff to monitor a pt who is not in labor or have a medical need for monitoring.
Our approach to this pt. would usually be similar to sbic's. We may have them stay on therapeutic rest w/ nubain or demerol or morphine and dc in the a.m. if no changes. It is tough when we get the same pt. coming in for weeks on end w/ the same c/o's of contractions, but very little cervical change. When we try to tell many of our pt's about prodromal labour, it just doesn't seem to sink in. Pit is a dangerous med and I think we use it far too much to pacify the pt. who is sick of being pregnant and the doctor who is sick of her.
Just last week we were giving two days of pit to a young lady who had presented to L/D numerous times in her pregnancy w/ contractions, but no cervical change. She was 39 weeks and "exhausted" from the prodromal labour. She didn't really want to walk or stretch or shower or do the jacuzzi when it was suggested. It won't help! She statrted throwing lates which persisted after the pit was turned off, so the doc suggested a section. She cried. She had not "had time to get herself ready for the idea of a section." She had even been offerred an elective section the prior week r/t all of her c/o's. She couldn't roll over in bed and stay there to treat the lates. It was too "uncomfortable." She was such a difficult person to deal w/. She was an emotionally fragile person who needed almost constant attention and reassurance. Her family was kind to her, but really fed in to her need for attention. I think there are a lot of women and families like this in the world today. Coupled w/ practioner's fear of liability, I think we are just perpetuating the McDonald's mentality in ob care.
Our approach to this pt. would usually be similar to sbic's. We may have them stay on therapeutic rest w/ nubain or demerol or morphine and dc in the a.m. if no changes. It is tough when we get the same pt. coming in for weeks on end w/ the same c/o's of contractions, but very little cervical change. When we try to tell many of our pt's about prodromal labour, it just doesn't seem to sink in. Pit is a dangerous med and I think we use it far too much to pacify the pt. who is sick of being pregnant and the doctor who is sick of her.
Just last week we were giving two days of pit to a young lady who had presented to L/D numerous times in her pregnancy w/ contractions, but no cervical change. She was 39 weeks and "exhausted" from the prodromal labour. She didn't really want to walk or stretch or shower or do the jacuzzi when it was suggested. It won't help! She statrted throwing lates which persisted after the pit was turned off, so the doc suggested a section. She cried. She had not "had time to get herself ready for the idea of a section." She had even been offerred an elective section the prior week r/t all of her c/o's. She couldn't roll over in bed and stay there to treat the lates. It was too "uncomfortable." She was such a difficult person to deal w/. She was an emotionally fragile person who needed almost constant attention and reassurance. Her family was kind to her, but really fed in to her need for attention. I think there are a lot of women and families like this in the world today. Coupled w/ practioner's fear of liability, I think we are just perpetuating the McDonald's mentality in ob care.
No doubt current pholosophy in OB has created this monster. It wasn't that long ago that patients actually believed that full term=40 weeks. Now they think the "baby can come" anytime after 36 weeks. We have joked that she's "post-dates" when we get a 40 weeker, but it really isn't funny. I have also seen many more babies not doing so well at birth because that supposed 38 weeker starts grunting and flaring shortly after birth. Does mother nature really need all this "help"? I don't think so.
I don't enjoy doing labors like I used to when women came in expecting to go through some discomfort, understanding it was part of having a baby. They didn't fear the process so and eliminating any possible pain was not the ultimate goal; having a healthy baby was. It must mean I am getting old when I start reminiscing like this.
I had a pt last night, primip, 30yrs, 1/90%/-1 (hey at least she was thinned out :)) contracting every 10 mins, 41 wks (hey- how did that happen- I didn't know you could stay pregnant that long under an OB's care :chuckle ), who was dying from pain so the OB kept her with plans to possbily induce if she did not change on her own. Anyway, she has one of her 6/hr contractions when the Ob is in the room and looks directly at him and in all serious says "I didn't think this would hurt". He was kinda flabbergasted and said "you mean having a baby" and she said "yeah". I did my whole "that's why its called labor, its hard work speech" but she still expected a painless birth. Sometimes I wonder where this "pregnancy isn't uncomfortable/labor doesn't hurt" myth comes from. Even the stupid baby story which everyone seems to watch shows "some" pain. Anyway....
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I am curious about how other L&D nurses deal with an admitted primip, not ruptured , irregular uc's, not really progressing, but oh soooo in pain
( 1/th/high ), this being the reason for admit, and refusing pitocin ...and BTW, you only have 5 labor beds and are backed up with pts waiting for a bed. Now I am all for pt rights and stuff but....do you just babysit her or what ? too high for an "asrom" , of course, you could send her walking but she still officially has a bed....it can be very frustrating... And she has a right to decide how she wants to do it....do you give her a choice : you take the Pit or you hit the road ? well that would be rude, so how do you solve this ?
Minou
Clearly, this individual is NOT a good candidate for pitocin or AROM induction at all with such an unfavorable cervical status. To induce would likely result in either failed induction and her being sent home ever more exhausted and feeling like a "failure"----or a csection to get the baby delivered. So in her case, I would have told her it was a good decision to defer induction and give her body time to see what happens.
Neither pitocin or AROM really are wisely-taken interventions for a low risk pregnancy where there is no medical necessity on mom's or baby's part to induce labor.
That is how I would have approached educating the patient as to why it would be a bad idea. I would not bother about how many beds or how short of staff we are. Most don't care---esp. the "all about me" crowd. So I make it "about them"---- and explain why it is not in their best interests to do certain interventions.
Also, our dr's are wonderful about therapeutic rest---we give morphine or Nubain/Phenergan to help them w/the pain and lack of sleep they experience in prodromal labor. Then, like said before me, one of two things happens. They either go into active labor or they get rest and it stops a while...Either way, at least the patient realizes we are taking her concerns and discomfort seriously and attempting to do something about it. And she is in a better place when active labor DOES ensue. There is not much worse than the disappointment and exhaustion of "failed induction".
Just an anecdote: Had a girl Friday night, 1st babe, came in 4cm and 80% and UC q4 min, clearly uncomfortable. Did not change her cervix x3 hours, so I offered Tx rest. Dr was very amenable to doing anything to make her more comfortable, but not inducing labor (she was scheduled following week). Gave her 15mg Nubain w/25mg Phenergan IM. Slept like a baby in-house for 3 hours while I monitored her and gave her every chance to kick into active labor (she lived nearly an hour away).
After 6 1/2 hours with us, I sent her home stable w/o cervical change and minus any contractions. Well, she was back exactly 24 hours later (with me again) this time, cervix 6cm and 90%. So, in giving her tx rest, we bought her a bit of sleep, a bit of time, the comfort of her own home and eating what she wanted-----(unlike when in hospital)--- and she was in active labor and got "going" the next night. It worked out well.....she had a beautiful baby at 0630 that next morning. It was a delightful birth for all of us.
There is a lot to be said about offering therapeutic rest/meds and reassuring patients we know what they are feeling is "real" and trying to help them cope. They more often than not will return within 48 hour in active labor, and when I tell them this, it seems to help.
from pain so the OB kept her with plans to possbily induce if she did not change on her own. Anyway, she has one of her 6/hr contractions when the Ob is in the room and looks directly at him and in all serious says "I didn't think this would hurt". He was kinda flabbergasted and said "you mean having a baby" and she said "yeah". I did my whole "that's why its called labor, its hard work speech" but she still expected a painless birth. Sometimes I wonder where this "pregnancy isn't uncomfortable/labor doesn't hurt" myth comes from. Even the stupid baby story which everyone seems to watch shows "some" pain. Anyway....
Minou
20 Posts
I do too....I guess ideally, this should be started before pregnancy but more realistically, in the doc's office...part of the initial prenatal care should be to educate the pt about the possible ways to do birthing...I guess if you're high risk at any point, well off you go to the hospital but other than that a midwife in a home or "alternative" environment would be great and certainly cheaper than the fast pace, production line of a hospital L&D I do believe we do too much intervening... low risk pts that want the natural way should probably not be in the hospital ( like a real birthing center close to a hospital, or home .with intermittent monitoring, heplock perhaps ) with midwives.
Also it never fails to amaze me how some pts come in with high unrealistic expectations ( birth plan and ball ) yet haven't got a clue...Has anyone possibly mentionned that pain might be involved here ? Or they are adamant about breastfeeding yet have not read 2 lines on it, do not have a clue about what to do....it's kinda sad really
So I guess it's education, education, education.