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.
Just FYI, on the VitK subject, the 2003 AAP policy statement says that oral administration of Vitamin K is linked to a smaller degree of efficacy, and that's oral VK supplements vs. IM administration. The oral supplements are still not enough to prevent VKDB in all newborns, but IM administration prevents VKDB in all infants save those with severe malabsorption issues.
RE: Transmission via breastmilk, it has been proven that VK transmission through breastmilk is poor and infants do not receive adequate protection through mom, even when mom is taking oral supplements herself. As I mentioned earlier, placental transmission is poor as well. See this link for the Merck Manual info:
As I said, ultimately, her plan sounds reasonable to me, and I totally understand her wanting to feel more in control of her birth, sexual abuse notwithstanding. I applaud her attempts to combine natural "medicine" practices along with those of modern day. As an NICU nurse, however, my opinion re: newborn prophylaxis is also research-based, and while I would respect any mother's wishes, I am understandably guarded about a mother who would refuse such interventions for her infant.
I also understand that this particular mother has, IMO, a reasonable plan and rationale for the PKU and HepB not being completed within the first 24 hours. I still stand by my concerns re: Erythromicin and VitK administration. :)
This is a very interesting thread. I concur with the posters who think that it's not what you say, it's how you say it that earns you the label of "difficult". Difficult patients are not about this or that particular intervention, they are about control issues. I find that the most difficult patients come from two extremes of the spectrum: 1) the ones who have absolutely no idea what is happening in labor and just want what they want--i.e. the baby out, now--and don't want to do the work to make the birth happen, and 2) those who want to control all aspects of the birth and feel terrified when they find themselves having to trust someone without being able to call six references and look up nine articles on the internet first. What makes these patients "difficult" is usually that they don't understand how quickly decisions and actions must sometime happen. In the half hour that it might take to convince a mom that putting her back on the monitor is a necessary thing, the baby could become severely compromised. Those of us who do this day in and day out all have stories of babies who go from looking great to bradycardic in an instant, and that's when those 4 minute 'splash and slash' crashes save lives. Those are the kind of risks that are always in the back of the L&D nurse's head when she is working with patients who are declining certain preventative interventions. The L&D nurse has seen many bad babies, and the patient often hasn't seen any. I actually think that for patients who truly intend to refuse interventions, the most responsible thing for them to do is birth at home, because then they really are accepting the full responsibility as well as earning the priveleges of their choices. I wish home birth were more widely accepted because I do believe it is a legitimate choice that needs to be available to all women, so that when they come to the hospital to birth it is because they want to, not because they have to.
Thanks for the info on the placenta. I had not heard of that but it makes sense. I don't think the hospital will go for it because of infection control issues. I guess you learn something new everyday!
If we had a standing ovation smilie I would post it just for you both. Thank you for taking the time to articulate (and research) the concerns that many were trying to express.
MANY OF US tried to articulate and have DONE research supporting our views, kids-r-fun!
You are right Deb, let me re-phrase my post:
Thank you:
NICU_Nurse: for providing links to reputable references to support your statements.
Beepers40: for summarizing what many have been saying in a very articulate post.
Deb: for providing a link to newborn screening info by state, I am sure many people were surprised to see just how much information is gained from those "little dots" of blood on the testing card.
Well, the original question was "would I be considered a difficult patient?" My experience is that it's not so much WHAT the parents want so much as HOW they act about it. The "difficult" label usually gets placed because of how the pt acts... showing "attitude" if you will. Coming it to have a baby with a birth plan and preferences and refusals without basing it on any research is gets difficult. This is obviously not the case with Keeper. She has her preferences and if it looks like the baby isn't doing well she's more than willing to allow interventions.
I think we've all had patients that refuse things without having ANY knowledge as to why. We had a NICU baby that had a pneumomediastinum, room air sats in the 70's and a RR above 100. The parents were the birth plan type that had already lost a lot of their desires (baby was a Csection) and they claimed up and down that the baby didn't need O2 and would be fine if we would just let him breastfeed and go to Mom's room. Couldn't be convinced otherwise. Difficult parents. Ended up taking the baby home AMA. These are the types we're thinking of when we refer to difficult pts.
I think whether the nurse labels a pt as "difficult" usually depends on how the pts act and react to things. We're all human and have bad days.
"Do I have any formal education as a health care professional? I've been waiting for this question. I do not believe a woman needs formal education as a health care professional to make informed decisions about her health. I think it is imperative that all women become more actively involved in their health care. This question was asked of someone in the homebirth community....sorry I can't remember the name. She had written a book one birth and was asked what credentials she had that would qualify her to make the statements she did about birth. Her reply: "I can read." I, too, can read. I hope you will not discount the wishes of your patients simply because they do not have the schooling you do. "
I would like to share my experience around this issue. I have three children; all were complicated pregnancies, with a c-section for the first birth and two VBACs to follow. With each birth, and a demise at 20 weeks in between the last two, I learned a little more about how things worked, with regards to both my own body and the general hospital environment. I read every pregnancy book I could get my hands on, talked to lots of folks, and was generally well-informed about my choices and comfortable with my decisions. I got so interested in pregnancy and labor in general that I decided to become a doula and help other women with high-risk pregnancies enjoy the kind of labor support that is often only offered to low-risk women. I entered training and was given a reading list with 10 or 15 books of required reading. I attended births as a volunteer at the local public hospital, often working with immigrant women who spoke no English and to whom our hospital system was terrifying. I loved my work and felt necessary and helpful, and felt even more well informed, well educated about how to help laboring women, and dedicated to my field. But I wanted to do more...and one day while driving home from a birth it hit me that what I really wanted to do was become a midwife. I talked to the midwives at the hospital where I volunteered about whether the licensed midwife or CNM route would be preferable; what decided me was the midwife who said, "I want to work with women of color, and most women of color deliver in a hospital, so that's why the CNM route was right for me." That winter I enrolled in a local community college to start taking prereqs for nursing school. Four and a half years later I graduated with a BSN, knowing that, just as what I had learned as a patient was a teeny fraction of what I learned as a doula, so what I learned as a doula was a teeny fraction of what I had learned in nursing school. Then I started my job as an L&D nurse and learned...that I knew nothing. That I could read every book and write every paper and ace every test, and spout every theory and statistic in the universe, and still it wouldn't matter, because there was no way to gain knowledge except through experience. My hands had to learn to palpate contraction strength, and feel for veins, and recognize the onset of chorio long before a temp started spiking. My eyes had to recognize the difference between strip patterns that looked okay and ones that heralded trouble down the pike aways, to see the difference between bleeding that was normal and bleeding that was not. My ears had to hear the change in heart tones that signaled I better get that patient back to the OR NOW, and to recognize when my Mag patient's SOB was due to incipient pulmonary edema and when it was her underlying asthma kicking up. And still, today, I am learning every moment. Every patient teaches me something new. My job is to prevent problems from happening, to prevent small problems from becoming big problems, and to provide care and comfort during those rare times when catastrophe is truly unpreventable. It is a hard, hard job, far harder than I ever imagined in all my days as a patient, as a doula, and as a student.
I am a mother and a nurse. Being a good mother is incredibly difficult. Being a good nurse is harder still.
I greatly respect every patient who takes the time to know her body, her own wishes, and what will make her feel safe enough to labor under my care. I respect the doulas who take the time to comfort and care for these women after undergoing rigorous and well-informed training themselves. I only wish these women would more often respect my experience as much as I respect theirs.
That says it all, Beepers40!!!! We nurses are NOT there to be adversaries to people's wishes. Most of us have seen nearly every scenario in the book. We WANT a healthy baby and Mom just as much as the patient does. For some patients...well, I guess they find this hard to believe. Our health care backgrounds make us their best ally.
The only problem we would have would be with the refusal of any electronic fetal monitoring (intermittant). You would also have to have signed refusal forms (for the baby stuff) before coming to the hospital (state mandates).
You say you are willing to have interventions if necessary. if so, why the refusal of any form of electronic monitoring (even intermittant?
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
betsy are you a member of the perinatal listserve? i see a lot of GREAT posts from a betsy in conn. there. just wondering. WELCOME TO ALLNURSES!!!!!!!!!!!!!!!!!!!
I have followed this post with much interest. As an L&D RN I have seen problems arise during the labor process (some of them direct results of intervention). But I also agree with the research that states 90-95% of the time, birth is low risk.
I am surprised at the confrontational attitudes of some of the responses. Sarah seems to be well informed about her decisions. And I agree, you don't have to have medical experience to be able to perform research. I for one, love to get pts who have made educated choices prior to arriving in L&D.
After planning a homebirth, I can understand many of your choices. I too was planning to skip erythromycin ointment, Vit K, and the Hep B injection, min. vag exams, eating through labor, no IV, and a waterbirth.
In the end, I arrived at the birth center ready to push with EGADS!!!, no EFM throughout my labor. I had no IV access, and required no Pitocin post delivery. So it can be done.
That said, I think Smiling Eyes is absolutely right. It is very important to discuss your desires with your doc/CNM ahead of time to be sure they are in agreement. Many hosp have "routines", but if docs/CNM request certain interventions or lack of, for their patients, the nurses will follow them. I know the facility I work in is geared towards natural birth with little intervention. I know a couple other facilities in this area that your desires would not fly in. They have high intervention rates. So looking for a hosp that meets your desires ahead of time is another wise choice.
I also agree with those who said the wording makes a difference. A birth plan is has a better reception if it is written " I prefer" or " I would like", rather than "I refuse" or "I want", etc.
I think most of your plans are doable, if checked into in advance with your doc/CNM and facility.
I think the only one we might have a problem with is all procedures done at bedside. We try to do bedside transition when the parents request it, but it unfortunately, depends on available staff.
I think the best option for you is homebirth, or a birth center. :) It's nice to know there are like minded individuals in nursing.
NICU_Nurse, BSN, RN
1,158 Posts
Just FYI, on the VitK subject, the 2003 AAP policy statement says that oral administration of Vitamin K is linked to a smaller degree of efficacy, and that's oral VK supplements vs. IM administration. The oral supplements are still not enough to prevent VKDB in all newborns, but IM administration prevents VKDB in all infants save those with severe malabsorption issues.
See this link from the AAP:
http://www.aap.org/policy/s030123.html
RE: Transmission via breastmilk, it has been proven that VK transmission through breastmilk is poor and infants do not receive adequate protection through mom, even when mom is taking oral supplements herself. As I mentioned earlier, placental transmission is poor as well. See this link for the Merck Manual info:
http://www.merck.com/pubs/mmanual/section1/chapter3/3h.htm
As I said, ultimately, her plan sounds reasonable to me, and I totally understand her wanting to feel more in control of her birth, sexual abuse notwithstanding. I applaud her attempts to combine natural "medicine" practices along with those of modern day. As an NICU nurse, however, my opinion re: newborn prophylaxis is also research-based, and while I would respect any mother's wishes, I am understandably guarded about a mother who would refuse such interventions for her infant.
I also understand that this particular mother has, IMO, a reasonable plan and rationale for the PKU and HepB not being completed within the first 24 hours. I still stand by my concerns re: Erythromicin and VitK administration. :)