dmw2010

I was taught in school that draining more than 1000ml at once might cause fluid shifts. Some hospitals (hopefully) have it stated in their facility policy. Now, if she was actively hemorrhaging and had a boggy uterus, that might be a different story....... Because if you only drained 1000ml at a time, you would have 2075ml left and she might continue to bleed because the uterus still won't clamp down.....

I am a L/D nurse doing post-partum now. How do you handle breastfeeding while the mom is taking medications? I'm particularly concerned about narcotics. I read that codeine is rated as L3, but might be L5 depending on whether or not the mom is a "rapid metabolizer" of codeine. (I would hate to find that out the hard way.) Of course, patients aren't routinely tested for this enzyme, and although it is rare, a case study said that a baby died because his/her mother was a rapid metabolizer of codeine. I don't find the breast-feeding drug references helpful (particularly the one by Hale) because there is a lot of gray areas in the L3 drug category. Maybe I'm not using it effectively. I asked a nurse at work how she handles the timing of narcotics and breastfeeding, but all she said was that she gave the narcotic immediately after mom breastfed. Well, in one circumstance, mom was in significant pain and so I gave her ibuprofen (L1) and had her feed the baby before giving her a narcotic. The ibuprofen didn't work and she continued to be in significant pain while we struggled with breastfeeding. Meanwhile, another nurse came in to see what the problem was, and told me to get her some pain medication, and then she continued to help her breastfeed. So it seems the nurses at my work didn't agree on how to manage this issue. What if she comes back from PACU and wants to breastfeed ASAP and is in severe pain at the same time? Is it safe to breastfeed right after giving her a shot of narcotic (like dilaudid or demerol or percocet or T3?) What if I give her a narcotic after a feeding and she wants to feed again in 1 hour already? Also, what should I advise her when she's discharged when her milk comes in (which means the volume of milk will be greater, thus the baby might get a higher dose of narcotic). What if the baby is preterm and in the NICU? I'm trying to be pro-breastfeeding and a good pain manager at the same time. I also don't want everyone baffled why the baby isn't feeding (or breathing) well, when all it ended up being was the narcotics the baby received from breastfeeding.

....wrong post

I've read a few birth plans in my day as a L/D nurse. I have mixed feelings about them. Whenever I hear that my patient has a birth plan, my immediate, gut reaction is to roll my eyes (in my head, of course). It seems to be a bad omen (it seems like they get a c-section more often with a birth plan- or maybe those particular c-sections are more memorable since it was the last thing she wanted in the world and we feel like we failed). It is intimidating because anything put into writing is supposed to be followed- or else. It tells me that the patient might think she is more enlightened than I am about how things should be done (even though it's her first rodeo), and it puts up a front that she thinks we won't do things in her or her baby's best interest. And I hope that she will understand why we have to deviate from the plan, for legitimate reasons, of course. I find that so long as I honor the plan as much as possible, and I am respectful in explaining why we have to deviate from the plan, she will usually cooperate and change her plan. However, I have heard (and seen) patients actively evade the doctor's plans, because they didn't fit in with "her plan," and that is always a nail biting scenario. On the other hand, I have seen patients who don't have a clue about anything with regard to the labor process. Never read anything, never questioned anything. And she ended up with an induction at 39 weeks for no good reason (doctor convenience), her water broken at 2 cm without being given the option of going home and trying again later (or 1 cm if he could get the amnihook in there; I cringed when he ordered amnicots for this purpose....), and ultimately, a c-section on my night shift for failure to progress. When I left the hospital, there was an ongoing discussion with the Chief of OB about this particular doctor's induction practices and whether they were appropriate. This is truly an issue in our profession. I think a lot of patients feel like they have to tell us what to do because they hear about women being taken advantage of (or she had a bad experience in the past and is determined to not let it happen again). So while I don't like birth plans, I understand them. The key is to form a trusting relationship with the patient and do what is right for her, whether she has a birth plan or not.

I've been doing Labor & Delivery, Post-Partum, & Nursery for 3.5 years now, and I personally don't pass any judgement on whether any mother, nurse or not, breastfeeds. To me, it's none of my business. Breast vs. bottle is only a small component of the bigger picture when it comes to nurturing a child to grow up healthy and strong. I know about the possible "dangers" of bottle feeding (obesity, necrotizing enterocolitis, etc.). But I think, depending on the individual circumstances, breast versus bottle isn't as clear as it may seem. After sitting through multiple breastfeeding courses, I will readily admit that breast milk is healthier than formula and I teach my patients this as well (partially because I believe it to be so, and partially because I have to tow the company line). However, I also don't believe in a one size fits all way of doing things. I am always deeply suspicious when a person of authority says that I have to do this one certain thing (ie. breastfeeding) and the other way is totally, completely, utterly wrong (bottle feeding), no excuses (lack of lactation, lack of latch, lack of time, lack of support, etc). That being said, I also believe the following: 1.) Not all mothers are equally blessed with an endless supply of breast milk. Just like some women are infertile, others can't lactate or have a difficult time doing so. 2.) Not all babies learn how to breastfeed effectively. 3.) Not all mothers have an equal opportunity to breastfeed due to time, logistics, etc. 4.) Breastfeeding while taking "most" medications isn't as safe as they say it is. I acquired a medication & lactation reference guide recently, and every time I read the damn thing, I want to chuck it out the window. Is it safe or not?! It oftentimes doesn't give a clear answer, other than to weigh the pros and cons. (And I feel like the L3 category is non-comittal in making that determination, which is where most drugs fall.) 5.) In general, our society and culture don't always support the lactating (or pregnant) mother in pursuit of what is best for her baby. 6.) I don't know why someone who has just had major abdominal surgery (a c-section, an already unnatural event) would want to breastfeed. (If yes, good for her, but if not, am I going to conclude that she doesn't love her baby enough?) I'm also going to go off on a tangent. I fully support any mother who wants to breastfeed in public as oppose to a bathroom stall. But reality is reality. You can't take your baby to work, and not all work places offer the time or sanitation to pump. As a RN on a busy labor & delivery unit, I can't imagine ever having the time to pump breastmilk (even once) AND eat AND go to the bathroom when necessary. (After all, you have to take care of yourself to better care for others, and that's not selfish.) Also, whether or not your nurse coworkers even like you is probably a big factor in whether or not they'll give you a break to go pump. (Women oftentimes don't support each other, even when they know better.) Night shift has nothing to do with breastfeeding except to say that working 3 nights a week, 12 hour shifts, and bottle feeding is probably stressful enough as it is. Many women don't have the opportunity to not work. I don't have children, but I've seen the challenge with my own eyes. We also all can't be the CEO of Yahoo, skip nearly all of maternity leave, and put a personal nursery and nanny beside our offices. When I have children, I plan on trying out breastfeeding, giving it a valiant effort, given that I don't have any contraindications for doing so. But if I give it up, so be it. If you figured out how breastfeed, despite a crazy busy life and flat nipples, I applaud you. But let's not demonize the bottle, because not all of us have the equal opportunity to breast feed effectively.