Would I be considered a "difficult patient?"

Specialties Ob/Gyn

Published

Okay, let me start by saying that I don't actually plan on birthing in a hospital again, and if I did, it would be because I risked out of homebirth, so the risk itself would probably make me more willing to compromise. So the question in my case is moot, but I have a lot of friends with the same desires.

I'm really just wondering if I came to your hospital as a healthy woman with an uncomplicated pregnancy and had these desires and a willingness to refuse the interventions to the point of signing off AMA, would I be labeled difficult or uncooperative. (Of course, with the disclaimer that if things became complicated to the point of danger to the baby, I would have no problem agreeing to intervention. For the purposes of this question, we're assuming all goes well).

- Heplock access, but no fluids. (I have bad veins, so the heplock is something I know is important for me.)

-Eating and drinking during labor, including herbal teas, such as red raspberry leaf and nettle tea.

-Intermittent monitoring with a dopplar. Initial twenty minute strip for baseline, but no monitoring with the actual fetal monitor after that. I would refuse the usual 15 minutes per hour rule.

-Complete freedom of movement. I would do whatever feels good and probably not ask first before bathing, squatting, etc.

-Initial lady partsl exam, but no others except at my request. I would refuse lady partsl exams offered or "required".

-I would not push at all until I had the urge, regardless of cervical dilation. (This is where refusing the lady partsl exams would work to my advantage).

-Hands and knees pushing position. I would absolutely not push in the semi-reclining or lithotomy positions.

-Immediate breastfeeding and no third stage pitocin. Baby in my arms for the first hour.

-I would refuse the hep B shot, vitamin K, eye ointment (I know I'd have to sign a waiver on that) and would choose to complete the pku at a health dept, rather than the hospital. I would require all newborn procedures to be done at my bedside, or I would refuse them.

-Discharge 12 hours after birth (or less) with the consent of the attending physician. (understanding that well established nursing, controlled bleeding, voiding, and urinating would all be prerequesites.)

Okay, that's my list. I really do want your honest opinions, and I don't mind at all if you would classify me as uncooperative. I'm willing to own the title if I earn it.

Thanks,

Sarah

Specializes in OB.

I think a lot of whether you would be considered "difficult" would lie in your attitude when talking with the staff about your desires for your delivery. Most of these things you outlined are well within the scope of "doable", but would be very difficult to emcompass if you just came in in labor and presented it as a list of "demands". If you came in ahead of time, having already discussed this with your provider, and talked with t

he staff, it would give time to assure that everything was in place including any waivers or disclaimers to cover the hospital and staff from liability for any untoward outcome from your refusal of certain procedures. I know I'd be a lot more comfortable caring for you if assured I wouldn't be hearing from your lawyer months or years later because the standard of care was not followed.

Remember too, that we are not working in OB with the intention of doing evil, unnecessary things to mothers and babies - we want a great outcome and good experience for both of you as well - we're not an adversary!

And isn't the newborn screen required 24 hours after first feeding?? There are minimal interventions, and then there are necessary interventions. Why no vag exam unless YOU feel necessary???? Then why not stay at home and give birth on the kitchen table.

Hi everyone,

I don't mean to hijack this thread but I have a ques. The OP and others mentioned erythromycin being used. What is it used for in preganant women or newborns ?? My doctor just prescribed it to me in the form of face swabs for my acne problems. Just very curious ~ sorry again.

P.S. Remember this ques. is being asked by non-nurse who is not too bright on this kinda stuff. :) :)

We use it to prevent/treat infections that can be passed on to the baby as it goes through the birth canal. It is gel we put in the eyes, mainly because of chlamydia.

Originally posted by MishlB

And isn't the newborn screen required 24 hours after first feeding?? There are minimal interventions, and then there are necessary interventions. Why no vag exam unless YOU feel necessary???? Then why not stay at home and give birth on the kitchen table.

There is some flexibility in the time frame for PKU testing. 24-48 hours is the norm where I have worked and it doesn't have to be done in a hospital. If it were an emergency issue in the first 24 hours we would ge the results a lot faster than we do!

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

Like said before, It's not USUALLY UP TO NURSES what interventions are nor are not accomplished---but PHYSICIANS/MIDWIVES and an expectant family would be wise in being assertive and proactive AND FLEXIBLE in discussing their preferences with THESE CARE PROVIDERS FIRST well in advance of their expected due date. And just sending a birth plan to the hospital is not enough, as the primary care provider will be the one who approves/disapproves requests, not the nurses. You have to SIT DOWN AND DISCUSS it FACE TO FACE so they understand how you feel and can explain why certain interventions may be needed from THEIR standpoint. THEN you decide whether this provider can meet your needs and philosophical goals at this point and perhaps select someone else, if not.

As far as PKU (REALLY NEWBORN SCREENING, as it should be CALLED) goes, it is wise to check with your state dept of health as any number from 4 to 20 different disorders/diseases (like galactosemia, sickle cell disease, hypthyroidism) are tested for and detected. PKU is VERY RARE but some of these disorders are NOT quite as rare yet have similiar or more devastating consequences when undetected and untreated.

I am concerned when people refuse such testing, but honor their refusals and document them as per protocol. It's up to the expectant family to educate themselves and make their choices as best they see fit, armed with the FACTS.

see this website for more info on newborn screening by state:

http://www.aboutnewbornscreening.com/stats.htm

I would like to say please reconsider the Hep. Immunization. There is absolutely no reason to not give this to your baby. This isent a disease to mess with and more than likely he/she will need it eventually anyway.

Why be at the hospital if you are going to reject their policies? There's not much more frustrating than a pt who comes in and doesn't want our help until things go wrong. Unless you know the rationale behind many of the "interventions" that you scorn, please don't reject them wholesale.

Specializes in NICU.
Originally posted by keeper

Thanks so much for all the replies. First, I wanted to reiterate that in the event of complications....decels, prolapse, fever, etc, I am always willing to throw my birthplan right out the window. I'm just not going to concede if it's only a matter of hospital policy. I will refuse if I think that is the only reason an intervention is being pursued. In the two hospital births that I did have, I was careful to choose a doctor with the same views and with an open mind. (He happily considered a lot of my birth an "experiment.")

I'm not pregnant at this point and don't plan to be for at least another year, and yes, it is a strange question, since I don't plan a hospital birth. I do hope to someday become a doula, and anticipate many of my clients will have the same kinds of requests and concerns. I wanted to guage what the feeling would be.

Many of you are in much more progressive hospitals than mine, so I'm glad to see what you are willing to allow. In mine, depending on the nurse, I WOULD have to loudly refuse many routine interventions to the point of signing waivers. I was considered a difficult patient simply because I had a birth plan, and it was nowhere near as militant as my post!

As for the newborn procedures, I have done a lot of research and just feel this is how I need things to be. I do get the hepB vaccine within two months, but I just don't feel we need to hurt a newborn that quickly after birth when waiting a week or so is reasonable. I do appreciate the info and advice.

For the record, I'm a pretty passionate person, and I have no problem being labeled as difficult. I have hopes that when I am a doula, my clients' rights of refusal will be respected, and I have even higher hopes that they will have to use them less and less as time passes.

Thanks again,

Sarah

I am not an L&D nurse, but I don't understand why you are willing to compromise the life of your baby. You don't want vag exams, etc., etc., yet you state that your birth plan will go out the window if you are having decels or a cord prolapse. How will you know?

Just being born hurts, never mind having meds given or testing done that might prevent further problems. You may be doing your research in all the wrong places. There are no guarantees that everyone has a normal, healthy baby. It just seems that way. Years ago, when everyone labored and delivered at home, moms and their babies also died at home.

If you are healthy, your pregnancy is monitored carefully, you may well deliver at home without any problem. Make sure you have a good back-up plan and a midwife who is skilled in newborn resuscitation.

Remember that you may be the one doing the work, but it is the baby's life.

It seems to me that if you are interested in helping women deliver, maybe you should go back to school to be a midwife, then you will be able to do things your way. You won't have to worry about your client's right of refusal.

Specializes in OB, Post Partum, Home Health.

I would absolutely respect and welcome you wishes. In fact, many of your wishes are things that I try to get my pt's to do-moving around, minimal vag exams (you would be surprised how many people are on the call light every 30 min requesting a vag exam) my philosophy sounds much the same as yours-initial exam, then maybe in a few hours if the pt wants (depending of course on the results of the first exam), and pushing before the pt feels the urge is pointless in my opinion. I would however investigate your reasons for refusing newborn procedures for your baby. I have found many pt's with a birthplan that refuses newborn procedures that have no idea why they refused them-someone just told them that they were bad, but they didn't have a clue what the reason for vit K was-they just didn't want their baby to have a shot. If you have all of the info and you still want to refuse, I would respect those wishes.

I would next ask you to reconsider a home delivery. I know that 99.9% of the time things go great at a home delivery, but I have seen a 45 min shoulder dystocia with a home delivery that ended in a xaphinelli (sp?) and emergency c-section 10 min after arrival to hospital by ambulance with the head hanging out-amazingly the babe survived but has severe problems. I have seen a pt on the verge of death because she gave birth in the tub at home and was bleeding way to much, because she was in the water, and stayed there for some time after birth, the midwife said that she didn't realize how much she was bleeding-by the time she got out of the tub, midwife realized bleeding too heavy, administered IM pit (illegally as she was a ley midwife), continued to assess, realized bleeding was still too heavy, pt was lightheaded, dizzy, nauseated, soon after unconscious, ambulance was finally called, brought to hospital and had to have emergency hyst and multiple units of blood.

I have had a near dead newborn brought to ER with temp of 92 and blood glucose of

Ok, I will get off of my soap box now. And I realize that you are probably more reasonable (or maybe educated is the word) than these people, but I still panic everytime I get a call that we are getting a patiet that "was attempting a home birth" because most of the time when they finally get to the hospital, it is usually a disaster.

I would much rather accomodate all of a pt's wishes in the hosptial than know that if I didn't she would risk it at home. I have pushed to get pt's dc'd 6 hours after delivery, no monitoring, no IV, no newborn procedures etc to get them to come to the hospital. I would recommend that you interview doctors or midwives, labor and delivery unit managers, staff RN's, and form your own "team" of people that you trust and are that are willing to accomodate your requests.

(you can come and deliver at my hospital if you want-I'll even come in special and take care of you!)

I too have had the dread ER call with the "ambulance coming in with pt attempting a home birth." Most of these are lousy outcomes, either for mom or babe or both. That being said, I also know that most home births go smoothly and well. We just see the disasters. I also agree with fergus, if you come in with the attitude of "I won't and you won't", you are bound to set people up to label you as you difficult. What do you care how they label you, unless you live in a small town, you will never see these people again. I suggest that you start off your birth plan with the fact that you are willing to work with the dr/midwife and staff for a safe and healthy birth, then list things that you would like to take place during your birth. Always mention that you have discussed these options with your dr/midwife,so everyone is on the same page. Also research the protocols at your hospital. I love it when the pt's birth plan states "I want no enema or shave" Ok, I haven't done either for at least 15 yrs, so that right there tells me you really don't know what happens in a hospital setting, and may not understand the ramifacations of some of your requests/demands. Please, please discuss your plans with your health care provider .

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