Refusing "Hospital Protocal"

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What happens if a woman refuses what a hospital considers "protocal'? What if she flat out refuses to have an I.V., amniotomy, EFM, ect.?

Specializes in nursery, L and D.

Oh man, I had my first pt at my new hospital that refused some procedures...........you would have thought she was an evil alien for all the fuss some folks were making! She had tried to home birth, and came in when her midwife said it was time for some help. She got an IV, pit, etc, just some things she didn't want. She wanted her doula to give her lady parts pressure to push against, I explained risk of infection, yada, yada, documented, and let them have at it. Went to lunch and my person that is orienting me made them stop. They didn't want the baby to be VE'ed, after 3 1/2 hours of pushing, doc comes in, does it while mom and dad are both saying no. The baby didn't look that bad, either. They didn't want cord traction, they did that too, while mom and dad were saying no. It was a mess. Then I find out that peds made them take the baby AMA because they refused to have an RPR drawn on the baby. Crazy. Is it a control thing with some staff?

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Specializes in Community, OB, Nursery.

I have seen them flip out over silly stuff like that too, Criss. Some peds at the hospital ;) don't even DO RPRs, depending on which group it is. Sheesh. Document the parents declined and get on with it.

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Specializes in General.
If the patient refuses a procedure after having risks and benefits explained to them, why is this such an emotional problem? In reality, continuous EFM and amniotomy have been proven to actually worsen outcomes. The need for an IV is precautionary at best if no meds are given (which is admittedly a rare case, but do most women actually need pitocin to deliver a baby?). Not everyone has the option of birthing at home or in a birth center due to insurance problems. This is such a frustrating example of the lack of evidence-based practice. Practice needs to be changed in hospitals to reflect current recommendations. Patients shouldn't be forced to submit to unscientific protocols to satisfy legal concerns.

Okay, one problem here, EFM and amniotomy have never been proven to worsen outcomes. The c/s rate has gone up, but outcomes worse, lets be reasonable. No way. Infant mortality rate in labor is next to ZERO percent, now studies do show that continuous EFM has not significantly decreased CP rates, but I don't want anyone to ever think it has worsened anything. Having a c/s is not the worst thing in the world, but having your baby die during a shoulder dystocia or asphyxia event can be. Next, I have to ask why insurance would prevent delivering at home? Seems to me that there'd be no charge. As an OB nurse, yes, it is frustrating to take care of these patients who "refuse" care, but show up, I agree...but refusal of care and refusal of active management of labor are two different things. Amniotomy and pit are not necessary, but ask yourself the question, why do you come to a hospital? For safety and the "what ifs", so if you also refuse ANY monitoring and at least a hep lock, then yes, stay home, because these are the ones who are going to sue in the end when things go wrong. IMO Can you tell that this is one of my pet peeves??

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Specializes in General.
If the patient refuses a procedure after having risks and benefits explained to them, why is this such an emotional problem? QUOTE]

Because if something does go wrong, you're still going to get sued. Signing a disclosure that the risks were explained to you is really a worthless piece of paper. Anybody can sue anybody for anything at anytime under any circumstances.

I'm with the response that suggested that person should go home to have their baby.

(Once had a home birth patient with her lay midwife who showed at our facility after 6 hours of pushing and no baby and announced to me that she didn't want an IV. Okay. And exactly what did you come here for then, if you're going to refuse to try other methods of getting you a good baby.)

I personally think that epidurals are way overused and over suggested as well. I love a great natural childbirth. But I'm also realisitic enough and old enough to have seen perfectly good labors go right to a bad place. In those cases, I am so thankful for a hep lock at the very least. How invasive is that really. In a perfect world no labors would ever go bad, no babies would ever be lost, but the world isn't perfect. I'm also too old to enjoy the massive adrenaline rush of a crash section anymore. There was a time---

I'm with you!!

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Specializes in Midwifery.
Okay, one problem here, EFM and amniotomy have never been proven to worsen outcomes. The c/s rate has gone up, but outcomes worse, lets be reasonable. No way. Infant mortality rate in labor is next to ZERO percent, now studies do show that continuous EFM has not significantly decreased CP rates, but I don't want anyone to ever think it has worsened anything. Having a c/s is not the worst thing in the world, but having your baby die during a shoulder dystocia or asphyxia event can be. Next, I have to ask why insurance would prevent delivering at home? Seems to me that there'd be no charge. As an OB nurse, yes, it is frustrating to take care of these patients who "refuse" care, but show up, I agree...but refusal of care and refusal of active management of labor are two different things. Amniotomy and pit are not necessary, but ask yourself the question, why do you come to a hospital? For safety and the "what ifs", so if you also refuse ANY monitoring and at least a hep lock, then yes, stay home, because these are the ones who are going to sue in the end when things go wrong. IMO Can you tell that this is one of my pet peeves??

Said like a true legal professional. Read the Cochrane reviews on the subjects i.e ARM & EFM.

CSs increase the risk of a woman dying, and then of course you have the increased risk of infection, blood loss blah blah.

EFM is unnecessay in low risk birth as is ARM. And scaremongering doesn't better your argument either. From what I've seen, from the processes used in US maternity care, you guys are probably causing more problems than you can imagine.

:o:o:o:o:o;)

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Specializes in General.

It's not that it is a U.S. thing, but varies from hospital to hospital depending on policy. I did travel nursing for 4 yrs and no place is the same. But as time goes on, and the more you get "burned", the more regulation one requires, in my case. I personally have been caring for 2 patients myself, that have had a cord prolapse while ambulating. Now I am working at a hospital that does not allow ambulation without telemetry monitor, when ruptured. That just makes me feel safer, ME yes, it IS about me when I'm the one responsible for what happens to her. And anyone who's been doing this for any length of time knows that things move very fast in OB at times, high risk or not, and I personally would hate to be inserting an IV in a patient while flipping from side to side, knee chest, shaving abdomen, inserting a foley, pre op meds, and getting ready for the c/section when tones DO go down and stay....s*#t happens, A LOT.

Oh wait, I didn't have the FHM on, so never mind, lets just get no FHTs in 15 minutes when I decide to spot check. Or better yet, in 15 minutes when I spot check, tones in the 40's and then give mom a CP baby to feed through a tube and deplete her life savings on for the next 10 yrs or so.

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Specializes in General.

May I ask what you consider "low risk birth"?? Do you have socialized medicine where you are? Yes, in the U.S. unfortunately we live in a very litigious society, hence the rates for OB doctors here. Scaremongerring as you said does not have to come second hand, live here, nurse here, be deposed ONCE and have to answer the "why didn't you's" and try not to change. Believe me, I have read more chronicles than could even be quoted. I have a degree in research as well. Either side can find whatever they wish to support whatever they believe, 10 times over. It comes down to the gut, and making the calls that matter.

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Specializes in OB.
May I ask what you consider "low risk birth"?? Do you have socialized medicine where you are? Yes, in the U.S. unfortunately we live in a very litigious society, hence the malpractice insurance rates for OB doctors here. Scaremongerring as you said does not have to come second hand, live here, nurse here, be deposed ONCE and have to answer the "why didn't you's" and try not to change. Believe me, I have read more chronicles than could even be quoted. I have a degree in research as well. Either side can find whatever they wish to support whatever they believe, 10 times over. It comes down to the gut, and making the calls that matter.

Okay, you are up at 2 am like me, so you've been doing night shift too long, LIKE ME. I agree with you and completely see where you are coming from. Unlike the Aussie up there :), in the USA unfortunately it has become all about CYA. If anyone does not know what this is, it's what your panties SHOULD do!:monkeydance:

What people don't understand, is that it IS all about the nurse. If you are not qualified, someone will pay, if you are not alert, someone will pay, if you make a bad call or miss something, someone will pay. Yes, patients deserve to make decisions regarding their care, but they won't always be the right decisions. I feel STRONGLY that if I am responsible for your care, I will do what I feel comfortable with, and when it crosses that line, the manager is to be consulted (me). Then the doc if necessary. There are ways to take care of difficult patients just like there are ways to deal with difficult nurses:trout:.

Scaremongerring as the Aussie stated actually CAN be a very valuable tool.

Thanks to ALL on these boards who do what it is that you do, and do it well!!!!!

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Specializes in Midwifery.
May I ask what you consider "low risk birth"?? Do you have socialized medicine where you are? Yes, in the U.S. unfortunately we live in a very litigious society, hence the malpractice insurance rates for OB doctors here. Scaremongerring as you said does not have to come second hand, live here, nurse here, be deposed ONCE and have to answer the "why didn't you's" and try not to change. Believe me, I have read more chronicles than could even be quoted. I have a degree in research as well. Either side can find whatever they wish to support whatever they believe, 10 times over. It comes down to the gut, and making the calls that matter.

Low risk as defined by the WHO. Look up Care in Normal birth. And you know the US ain't the only place that patients sue! It is obstetricians and lawyers who shoot themselves in the foot here, promising perfect outcomes, what else are women to expect when they are hooked up to every gadget "just in case". Playing 'expert' and knowing whats best, when there is no scientific evidence for much of the procedures routinely used. Then there's a bad outcome, which the gadgets don't prevent, and wow, woman sues.

I've had my fair share of involvement in 'legal' issues too, unfortunately your system has caught on else where. But that doesn't stop me from providing evidence based care to women and encouraging them to be responsible for the decisions they make. And treating them with kindness and respect and facilitating an outcome that is best for them and there babies. ie as normal a birth as possible. Intervention is great when required and yep I've had cord prolapses aplenty too and it ain't such a huge deal to throw em on a trolley head down bum up, wiz em to ot where the damned anesthetist can site the iv in a flash! All great outcomes too....

And I would love any references that you have that prove that interventions around birth such as CS or instrumental birth don't worsen outcomes?

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Specializes in OB.

Well, I can go with what I know. Alabama RN is a southerner, so take it easy on her, up here we yanks will argue. I personally labored with my first baby for 21 hours, had a c/s and was handed a healthy 10 lb 5 oz boy!!!! Should he have stayed in until he reached 11 lbs?? HECK NO! My outcome was better for my c/s, this I know. There will always be evidence to support your opinion and hers, plenty, just google it yourself. These boards are for opinions, and she has hers, you have yours, you both have enough experience to be correct. Now my panties are bunching by your references the "we" americans are making your system worse, we have taught you nothing, sent you nothing. If your system is turning toward our ways, maybe there is some merit. Either way, we don't make the rules. So go with the flow, and remember your patients rights.....not just the right to refuse, but also the right to a favorable outcome. Its all I wanted 20 yrs ago.

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Specializes in Midwifery.
Well, I can go with what I know. Alabama RN is a southerner, so take it easy on her, up here we yanks will argue. I personally labored with my first baby for 21 hours, had a c/s and was handed a healthy 10 lb 5 oz boy!!!! Should he have stayed in until he reached 11 lbs?? HECK NO! My outcome was better for my c/s, this I know. There will always be evidence to support your opinion and hers, plenty, just google it yourself. These boards are for opinions, and she has hers, you have yours, you both have enough experience to be correct. Now my panties are bunching by your references the "we" americans are making your system worse, we have taught you nothing, sent you nothing. If your system is turning toward our ways, maybe there is some merit. Either way, we don't make the rules. So go with the flow, and remember your patients rights.....not just the right to refuse, but also the right to a favorable outcome. Its all I wanted 20 yrs ago.

OBGYN Too Long your story of your birth is about a timely CS. Well done to your careprovidors for delivering your baby the way you needed it to happen. I'm not arguing that there should be no CS. But one story doesn't make it right for every woman. And no I don't blame americans for our pickle, that is our own doing!! God knows it is!! Our current CS rate is actually higher than yours last time I looked. With more women experiencing PND and many other untoward outcomes that go hand in had with high interventions rates around birth. There is more to birth than cutting or pulling out a screaming baby with perfect cord phs, so no one can sue. And I am not saying that women don't want the perfect baby. That is what is important to all women.

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Specializes in ICU, SDU, OR, RR, Ortho, Hospice RN.

I wonder what her reasons were to refuse all this??

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