Refusing "Hospital Protocal"

Specialties Ob/Gyn

Published

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 Specializes in L/D, newborn, GYN, LTC, Dialysis.
Well done! So how long would you leave a primip before you start her pushing? Do you wait for how ever long it takes for the head to decend?

:bow::bow::bowingpur:bowingpur...to all you fab people working hard to give women the best outcomes!!!

I am happy to leave her for as long as it takes to get baby down low (if baby is stable of course). IF a baby is stuck in a difficult position, e.g. OP, She will be turning from side to side a lot with my help. I agree with Beckinben: Laboring Down is the KEY!

PS our epidural rate is over 85% as well! I love to get the (increasingly rare) naturally laboring patient to work with.

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I am happy to leave her for as long as it takes to get baby down low (if baby is stable of course). IF a baby is stuck in a difficult position, e.g. OP, She will be turning from side to side a lot with my help. I agree with Beckinben: Laboring Down is the KEY!

PS our epidural rate is over 85% as well! I love to get the (increasingly rare) naturally laboring patient to work with.

Our epidural rate is probably higher....we have 1 newer doctor who thinks he's wonderful who we don't call when his patient is complete if they have no urge but if he happens to come in and check somebody and they are complete he'll say "let her labor down" then come back 10 minutes later and say ok let's push....never seen so many lacerations.

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Specializes in Midwifery.

I completely agree with all your comments......I am not surprised because you have so many epidurals and are doing a great job, but as SBE said I think the combination of people has to be right. We have training docs, and midwives who rotate through our DS, and some of them don't understand the concept of LEAVING a woman with an epidural go for as long as it takes. We battle with them every day. Our anaesthetists are also training so one day the block will be up to ones eye balls and the next day patchy and not working!! Our epidural rate is about 20% and our CS rate is around 23%.

Smiling Blue Eyes is the way you do it based on the Penny Simkin stuff? You know the going from side to side with an OP?

And I agree fudging things is something that must be common on BOTH sides of the world!

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Specializes in postpartum, nursery, high risk L&D.
If a baby is OP, especially, they will spend a LOT of time turning and off their backs! I keep them I have no problem having them push on their sides, either. This works great to turn a stubborn OP or transverse presentation, as we know.

Sorta OT, but modified Sims' position works just awesome to turn an OP baby

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Oz: I am Absolutely a student of Penny Simkin here, and Ina May Gaskin, as well. I have read many books on midwifery and labor suport/doula techniques. I own a well read copy of Varney's Midwifery as well. I am only frustrated that so many patients are unwilling to do much to participate in their own labor experiences, but lay on their backs and watch TV. When their babies get "stuck" I work hard to help them see that the level of their participation and attitude will definately affect/effect the kind of outcome we will see in the end.

We can modify their (Simkin et. al) techniques, adapting them to "epiduralized" women and they often do work!

I have learned so much in 10 years as a nurse. I started out in a rural hospital 10 years ago where the rate of 4th degree lacerations was HUGE; probably 20% or greater, no lie---- (I actually thought this was normal, having not seen anything different). The epidural rately, surprisingly, was much lower, somewhere around 40%, if that. So it was, I believe, a combination of truly frightened moms, uneducated staff, and making people push way too hard, too soon, that led to this. Also the episiotomy rate was much higher. Supporting the perineum was not something I saw or was taught there, either. What I did see, was a desire on the parts of the doctors to "get the baby out" ASAP, as if the mom's body was foreign or hazardous to his/her life! When I worked other places, I saw the differences and was shocked at what I did not know.

There as so many factors that contribute the degree of success of our outcomes, clearly. I am learning all the time, how much I really do not know.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Sorta OT, but modified Sims' position works just awesome to turn an OP baby

Not at all OT. And yes, you are right. Sim's position is excellent for turning baby. This is accomplished by turning a mom as far to one side as possible, supporting her with pillows, as much as she and her baby will tolerate. Great point. I have a couple techs who, when a patient "looks like a c-section" wait to set up the OR when I am in there with those moms. It's not cause I am "all that" but they know I will do all I can early-on to help facilitate a lady partsl birth. This is only accomplished with patience and a good attitude. It's challenging, but worth it. I have learned from some awesome nurses and midwives in the past, thank goodness. Also, some people come in with "csection written all over them". You know what I mean-----that is discouraging to me, but a fact in OB nursing today, at least, in the USA.

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Specializes in postpartum, nursery, high risk L&D.
I am only frustrated that so many patients are unwilling to do much to participate in their own labor experiences, but lay on their backs and watch TV. When their babies get "stuck" I work hard to help them see that the level of their participation and attitude will definately affect/effect the kind of outcome we will see in the end.

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One of the experinced labor nurses I work with (our labor guru) recently gave me a tip for working with those unmotivated moms. She said if you present it simply like this: "your baby needs you to______" (position change or whatever it is) that can make all the difference in the world with those moms who just don't seem to want to participate much. it does seem to help.

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Lunges also work great for turning OP babies. You can even do them with moms who have epidurals, depending on their levels. I had a prime do this to rotate her OP baby. She delivered direct OT without so much as a stitch. The key to getting moms to participate is let them know that it will facilitate the birth and help them avoid a section. 9 out of 10 times if they know there is a purpose they will do as I suggest. Our epidural rate is only about 40% so we see a lot of natural labours

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Very interesting discussion . . .

If a woman's refusal of X proceddure (IV, EFM,lady partsl exam etc) doesn't put safety in question, it shouldn't be such a "control issue" with hosiptal staff.

For those here that assume that a woman should seek care elsewhere: (if she wants to refuse stuff) Sadly not everyone can got to a birth center or find a midwife. For example, here in Redding, CA we have only ONE hosiptal (well we have two but only Mercy delivers babis), which has banned VBAC'S and has a very strict policy regarding "routines" We did have one local midwife, but most of our OB's here are VERY "by the book" So in short, women here have few options.

In the end, women should be the ones making these choices, but at the same time they also need to own their decisions and the effects thereof. (be they positive or otherwise)

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Specializes in OBGYN, Neonatal.

This has been a wonderful topic for me. I'm learning a lot!

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Just a thought . . . .

I understand alot of you have had bad experinces with controling fathers, obnoxious birth plans etc.

How would each of you deal with someone that was pretty flexible but was adament about refusing internal exams? I only ask because a dear friend of mine just had her second baby april 9th and guess who got called first, LOL Anyhoo, she told me all about it. Since her first birth went so well she didn't have a "plan" typed up or anything, and her OB was more than willing to work with her, but the one thing she was not going to compromise, was her refusal of lady partsl exams, which her dr had no real issue with. She told me that the two nurses she had gave her a bad time about it and she was having a hard time understanding, since baby was doing great.

I told her that since I wasn't with her I really couldn't give her any advice, but I did say that perhaps the two ladies were having a bad shift, or maybe they just wanted to you do as you were told with no questions.

I aslo touched on the fact that it would have helped if she had explained why she was refusing, but she said that she wasn't comfortable sharing personal stuff with someone she doesn't know.

I understood exactly where she was coming from but she did say that next time she was going to explain her reasoning.

Otherwise her birth went fine, no problems, no stitches, YAY! She came over yesterday actually, her little boy is absolutly adorable! And eating like a horse too!

Before she left she asked me what I would do in her shoes . . . . (we both have similar abuse issues from our childhood) I just hugged her and said " I would have been honest about why I was making that choice. But if you didn't feel comfortable sharing stuff with you nurse, that's okay too. You need to do what you are comfy with."

Looking back on this, I don't blame her for not wanting exams. Even though I have worked through my childhood "issues", the idea of someone doing that when I'm in a very vunrebale situation, just doesn't seem right. I learned that first had about four months ago when I had my misscarriage, I was only two months along. I was terrified and devastated. My primary care provider was out of town, so I had to go to the ER, the nurse that was with me was awesome: respectfull and very supportive. It was the Dr that ****** me off: without even so much as a "hello" he comes in, lifts my sheet and tries to "dive in" Well, I nearly kicked him in the groin trying to scoot up the bed.

I told him, I didn't mind being checked out, but he wasn't going to be the one to do it!

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This issue coems up occationaly and i have found that most of the peopel who bring them up are fairly reasonable if you acknowlage there right to make decistions for them selvs and for their body. "I explain we will not do anythign to you you dont fully and completely understand (unless it is life critical even in this situation you have the right to refuse but it would be wise to ask questins after the fact) - so before you do soemthing we will talk about it and the 2 of you will decide. then I say we dont do things unless there is a reason. The reason we want you to have an Iv is becuse the most common emergencys we see are bleeding, in the case we have to give you lots of fluid to make up for what you are losing, its also required for an epidural but the big reason is that in a life threating situation an Iv is the only way I can save you and if it takes 5 min to start one thats 5 minutes of risk .

I can run on and on like that until they see my side or we all dose off - but I have only ever had 1 patient refuse an IV after that . She looked at me and said "you dont know nothin, how many babies have you had? Ive had 5 (she didnt mention that they were cocain premies blown out at 16-25 weeks) you dont know what your talking about get out of here, trying to tell me you know about babies FU! - at that point I considered her informed on the procedures and documented the converstation.

But the real point I want to make is that a rational person when made to feel they have coice and given the information to make it will useualy make the right decistion.

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