Refusing "Hospital Protocal"

crissrn27, RN · Jul 10, 2007

I have never had a pt refuse everything. The one time we had a pt that wanted minimal intervention, including no vit K or eye gtts, the pedi had a fit and asked her why didn't she just stay at home to have her baby. Which is crazy since here in NC we have no CPM, most CNM practice in hospitals, and this just really isn't an option unless you want to do the unassisted thing. She consented after she was exhausted from the birth.

I did have a 30 weeker come in laboring and refused any intervention, because she was "tired of beng pregnant and the baby is ready"........that is a different story than what we are talking about. If a woman knows what she wants, and has a good strip, there is no reason she should have to stay strapped to the bed with monitors and IV's.

I wish more women would question the need for some of the useless stuff we do to them. I have never, ever had a pt that was allowed to have intermittent monitoring, all had continuous. All have IV's with fluids, most (90%) have pit, 50% have epidural, around a 26% c-sec rate. Take the baby soon after birth for 3-5 hours, no one allowed in nursery for bath, etc. I will start at a different hospital soon and I hope to find more evidenced based practice. I know, personally, if everything is OK when (if) I have the next one, I will be refusing some things. If I have the baby at my current hospital it is sure to tick some folks off, but oh well. Women should have the option of having a hospital birth without facing angry nurses and doctors because they don't want everything.

SmilingBluEyes · Jul 11, 2007

It depends on the intervention being refused. It's not a huge hairy deal to refuse IV if the mom is low risk and healthy. Nor it is unreasonable to refuse continuous EFM unless they are high risk or have pit or epidural drips running (usually not a problem in such cases, anyhow). There is NOTHING wrong with a woman and her S/O wanting some control over what happens in "their " birth experiences, in the least.....

There are some cases, of course they may refuse anything at all, and it is contraindicated in safe delivery of care,-----in some such cases, we will have them sign AMA forms(like when they refuse all blood products) if they insist. Like I said, depends on situation and what they refuse. As in the case of the 30 weeker, you have work to do to convince them why stopping PTL at this stage is critical and usually you can reason with people IF you do not come across as snotty, know-it-all or threatening, but as respectful and helping them see why what you want to do is beneficial for them and their babies. Communication skills are never more important than they are in such cases.

We also do have the OB/GYN enter into the scene and talk over with them about just why they refuse, any benefits that may be for them not to refuse, and even if safe, allow them to transfer care to another institution where their wishes will be met, if they can't be where we are. It takes a lot of subtle yet respectful dialogue (not lecturing) and give and take, to work these thing out, but it's also well worth it to do so and have everyone (reasonably) happy and safe as possible.

Elvish, BSN, DNP, RN, NP · Jul 11, 2007

It's kind of funny/ironic that some nurses and docs get their knickers in a wad over things that we didn't even do 30 years ago and somehow the human race survived.

If I had to go back & do it over, I wouldn't have gotten e-mycin drops for my son, nor the HepB. Some nurses I work with get all worked up when a parent declines the HepB for their baby. "Doesn't she know the baby needs it?? Doesn't she know it's good for him?" A LOT of people just want to wait a few months to start the series, and what's the big flippin' deal? Ditto for EFM, IVs, etc.

CEG · Jul 11, 2007

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If I had to go back & do it over, I wouldn't have gotten e-mycin drops for my son, nor the HepB. Some nurses I work with get all worked up when a parent declines the HepB for their baby. "Doesn't she know the baby needs it?? Doesn't she know it's good for him?" A LOT of people just want to wait a few months to start the series, and what's the big flippin' deal? Ditto for EFM, IVs, etc.

The other thing that doesn't make sense is that most doctor's offices (at least around here) use the 3 series COMVAX which includes the Hep B. So actually babies who get the Hep B in the hospital are getting four shots.

It really doesn't make any sense to say that we start Hep B in the hospital because people don't return to get their baby's shots done... the people who don't won't complete the series anyway and the baby still isn't protected and the people who so are giving their baby an unnecesary dose. Hep B at birth is a really strange policy in my mind (one that I skipped for my own children).

eden · Jul 11, 2007

Really, unless you are in a high risk category, hep B is not needed. Here it is not required unless you are in one of the high risk groups.

Studies show that IA (we just listen q 15min and if there is something of concern we pop them on the monitor and monitor accordingly) is just as effective as EFM and it cuts down on primary c-sections due to the subjective nature of interprteing EFM strips, with outcomes that are just as favourable.

Same goes for an IV, if a woman is low risk there is no need for even a lok. At our facility we have many a woman labour and deliver without so much as a lok, with no problems. In the event one needs to be started post partum we again have had no issue. We have a policy for who does/doesn't need IV access but just walking through the door in labour does not necessitate IV access.

Elvish, BSN, DNP, RN, NP · Jul 11, 2007

I want to give birth at your hospital, Eden!

eden · Jul 13, 2007

Sure Arwen, it looks like you just have to come on up north of the border:). It works well and if I ever moved elsewhere that rquired IV access, hep B and EMF for the entire labour, I'd probably be labelled a difficult patient:lol2:

danissa, LPN, LVN · Jul 13, 2007

just another wee question from this UK Midwife. Do all women in the states who come into hospital labouring have an iv cannula inserted.."just in case"? It's not something we would do as a routine thing here, thats why I ask. Also continuous fetal monitoring in low risk cases...is that whats done in the US? What about mobilising in labour? I know i've gone a bit off topic, but just curious!

crissrn27, RN · Jul 13, 2007

Can't speak for everywhere, danissa, but where I work all have IV on admission, continuous EFM, no walking, very, very occasionally we will have someone want to rock or do the birthing ball and the nurse holds the EFM in place, and if that doesn't work it is back to bed.

danissa, LPN, LVN · Jul 13, 2007

Criss..does it make any difference at all if they are prim or parous women?? If they want to mobilise then they have to then be restricted with someone holding a fetal monitor on them?? again, just wantin to know what goes on in different countries!

eden · Jul 13, 2007

Honestly the best thing for labouring women is to be mobile. Being strapped to the bed is counter productive .

crissrn27, RN · Jul 13, 2007

Criss..does it make any difference at all if they are prim or parous women?? If they want to mobilise then they have to then be restricted with someone holding a fetal monitor on them?? again, just wantin to know what goes on in different countries!

Not at my hospital....its all bed, all the time after admission. They do "walk" pts if they aren't sure they are in labor. They walk for an hour, then if no change sent home, if change they are admitted and put to bed....its crazy, and part of the reason I am moving to a different hospital on the 30th! We do lots of outdated stuff. I had my babies at my hospital.......the first two were before I knew any better, the last, my dd, was before I started working there. I wanted to rock in the chair, had a great strip, and they sent someone to hold the EFM on me, when she couldn't get a good trace, I was put back to bed. Won't happen next time, if there is one. I wish more women would speak up there!