We've changed the care practice at work (for now, just with one MD group) to start a continuous piggyback of D5LR fluids in addition to the regular IV fluids (LR) to all laboring women that are not diabetic.
We are still utilizing plain LR for boluses for pre-epidural fluid loading and for intrauterine resuscitation (when the fetus is in distress). D5LR will not be used as a bolus at any time.
Why D5LR? Because women are exhausted after long labors, and it has been decided that we need to give them IV glucose (D5LR) to maintain a regular glucose (energy) level during labor. There was a study linked to the policy/guideline change, but I do not have it readily at hand to share with you. Will post it in the near future though, after I have a chance to read it.
I question this new care practice. What about "allowing" women open access to fluids and light snacks during labor? What she is craving/having the urge to eat or drink will usually help dictate what her body really needs to fuel itself during labor. I recall eating ice cream in early labor, and craving protein: it was what my body needed at that moment in labor. Once I hit active labor, I didn't want anything more than little ice chips. Then again, I had rather short active labor phases. I simply didn't require very much in the way of glucose intake during active labor. I had stored it up in the early labor phase, where I ate and drank whatever my body craved.
Even though we (nurses) are caring for women ("patients") in a hospital birthing unit, we are forgetting how to truly care for laboring women. We are continuing to medicalize what is a rather normal, instinctively driven process. Why must we feel the need to continually interfere with a process that works well on its own?
I absolutely agree and feel that when we do need to intervene, we should intervene appropriately. However, utilizing D5LR in a normal labor is not an appropriate intervention. We need to get back to our natural roots: less intervention!
Seeing more interventions to a natural process has definitely opened my eyes (even more!) to why I am becoming a nurse-midwife.
21 comments:
I hate, hate, hate IV's and it has nothing to do with the little needle. I get so doggone puffy if I've had one, and last time my arm was so big the bracelet was cutting into me. My bracelet itched terribly and I had sweat underneath it. I was miserable all over, just a fluid filled mess. Also, the nurse wouldn't let me sip water at all. I was so dry and my throat hurtfor a few days. It' just terrible to not be allowed anything by mouth, and to have the effects of the IV. I was sweating like crazy too, and they kept it hot in my room. Ugh. The labors without an IV have all been better. With the IV I find I shake more, I've had the "wide open" kind just running and running. In fact, this last labor they had the IV in for over an hour afterward and didn't allow me to eat or drink. I was going nutz.
Blessings!
Dawn
Here's my post on a bulletin board/blog thing about my experience with a midwife after having OB's and family doctors for six births and through miscarriages....
http://www.mom2momkc.com/?a=profile&u=603&t=blog&blog_id=2830
You can share if you'd like.
Oh, and it's just the first meeting...not to the birth yet!
I suspect that allowing the mother to eat and drink more during and after labor would improve the odds of breastfeeding success, too.
At the hospital where I gave birth (and was born for that matter) they let you eat and drink as desired and even have a juice machine and snacks like graham crackers available on the unit. The only guidelines from my midwife about what to eat/not to eat were when she suggested that I have some chocolate to wake the baby up (he wasn't reacting to the contractions) and to consider that "what goes down may come up" when choosing what to eat.
Wait, wouldn't that be like downing a 2liter of cola? That's a LOT Of fluids to be pumping into a person for no good reason. And how is this going to affect the baby's ability to regulate sugar immediately following the birth (a question which, if the answers are negative, begs the next: how will it affect breastfeeding?).
What if the mom refuses an IV?
Are the women given informed consent about what they are getting in their IVs? I am always amazed how when a mom has an IV, nurses just pop in a new bag of something without telling mom (Thinking mostly of pitocin after baby has been born.)
Please correct me if I'm wrong, I think you CAN refuse IV if you have no complications and you also CAN ask for sipping water/ice or eating light snacks if you want & really hungry but you might have to "fight" the hospital regulation to get these ????
I've only had one baby, so I'm no expert. BUT, my midwife practice (in a hospital) allowed me to chug as much water as I wanted right up to the last push. They even encouraged me to use straws so I could drink easier. My doula held the bottle right to my mouth and I felt like I couldn't get enough. I cannot imagine it being any other way!
Here's a link to the recently revised ACOG guidelines on oral fluids in labor - perhaps you can share that somewhere at work.
http://www.acog.org/from_home/publications/press_releases/nr08-21-09-2.cfm
With my last delivery (#6) I had so many IV fluids that I had an excess of fluid that seemed to affect my right breast and breastfeeding on that side. It was really frustrating! I went to Kellymom.com and obtained exercises I could do to try to back the fluid up so that my milk could start flowing. It was probably about two weeks of battling with that right breast. Ugh!
With my best, no-intervention delivery I , too, ate ice cream early on. It was a perfect labor and quick delivery. With other labors I remember being so hungry and weak probably from needing protein and not just sugar, that it affected my ability to relax. I got epidurals with a couple of those births, but would have preferred food instead to have some stamina to manage my contractions. Anyway, I totally agree with your post. Thanks!
There are a couple of reasons why simply allowing unlimited oral intake of food and liquids, which sounds so sensible, doesn't work in practice.
1] Peristaltic action shuts down in labor. What's in the stomach, stays there. That's fine for carbohydrates, since they are absorbed directly from the stomach. However...
2] Whatever else is in the stomach is often removed when the patient vomits, as she frequently does when about 7 cm, or going into transition. So the patient isn't getting any benefit from either all that fluid she's taken orally, or any nutrients.
3] There are all the implications of a full stomach regarding anesthesia. With the best intentions in the world for an unmedicated NSVD, sometimes you have to do a crash C/S, and even today, under general anesthesia. No one wants Mendelson's Syndrome.
In my experience, as a CNM with 40 years' under my belt "in the trenches", light oral intake [ice cream is a good idea, btw] is fine. But in a long labor, you aren't going to be able to supply enough energy or fluids with ice chips, etc. and I've seen women wind up with bigger interventions, such as C/S, because they began to have signs of fetal distress because of dehydration and hypoglycemia.
BTW, if a patient is getting so much IV fluid, it is even more important to make sure she empties her bladder frequently!
And lastly, you should be becoming a nurse midwife in order to give your patients the SAFEST and best births, not simply the births "with the least interventions". If an intervention is indicated, you should be using it. I hope what you meant was "the sensible use of interventions".
For the record, an IV fluid containing 5% glucose (like D5LR, or D5whatever) contains only 200 kcal per liter of fluid, all in glucose form (a simple carbohydrate.) If given at an 8 hour rate (125 ml/hour) that's 25 kcal an hour. While you can't supply enough energy with ice chips as astutely pointed out, most women can take a couple oz or more of clear liquids an hour without too much difficulty and get more calories than available from IVF, and we can certainly reserve IV fluids for those who cannot.
My big issue with IV fluids has nothing to do with being more natural or whatever - it's all the third spacing of fluid I see in women who receive large amounts of fluids. If we have to have them - for the dehydrated, vomiting woman or similar, or for fluid support for an epidural, fine, but if I can avoid them, I do. All that fluid in the breast tissue, and even the legs and perineum is uncomfortable, and interferes with early breastfeeding if severe.
Even ACOG has changed its opinion to allow oral fluids in labor and even before an uncomplicated, planned cesarean.
I work as an L & D nurse at a community hospital. I was wondering what your policy is surrounding IVs in low-risk laboring women? Do you need to have an IV in for all women who come in labor, or a saline lock, etc.? At my hospital if a women is GBS neg, and not planning for epidural, and low-risk we don't necessarily have to place an IV or saline lock. That doesn't happen all that often, but they are not mandatory on everyone. I was just curious what happens at your hospital - and I also really enjoy reading your blog, thanks :)
I was curious about the same thing as Danielle. Being GBS neg, low risk, no complications, no-pain meds, I was permitted to skip the IV in my births at two different hospitals. An IV was standard procedure, but they were willing to omit it with my care provider's permission. I didn't even have whatever they call the IV substitute (heplock?). What's the reaction at your hospital when a woman - assuming no risk factors - wishes to refuse this "precautionary" intervention?
Danielle & Megan: If the woman is lucky to have a CNM who is open to no IV site (no fluids, no heplock), then the woman can forgo the IV site. However, with every doctor that I work with, and quite a few of the CNMs, they will rationalize a need for an IV site.
I don't understand the limited fluids/foods thing myself, especially for women with long labor because it seems like preventing a woman from becoming dehydrated and exhausted from lack of nourishment would be more important than the potential risks if there was an emergency surgery.
How do they handle unplanned surgeries when the person has not been in the hospital for the previous 2+ hours, and may have eaten a large meal just before the trauma occurred, and why is a birth so different?
My doctor told me that our hospital allows a "limited" amount of fluids, in case of surgery [I'm fat, so I figure it's expected I'll need an "emergency c-section, but that's another rant]. I drink at least 2 liters of water per day as is, and become dehydrated easily, so I doubt that's going to cut it, so my plan is to have a thermos of ice and some G2 [lower-calorie gatorade], as well as light snacks, in my bag and have my husband or someone slip them to me if I need them when the nurse is out of the room.
My comment/question is similiar to the last one. I'm curious what the nurses/doctors/hospitals do when the woman just eats/drinks? I have to labor/deliver in a hospital (no choice, don't want to) and I don't care if they tell me I can't eat or drink. I'm just going to eat and drink as my body wishes (only wanted very limited intake during first labor/delivery). What exactly does the hospital think they can do if a women decides to take a drink or have a snack? (I mean this in all seriousness)
I second Antigonos' reply.
"And lastly, you should be becoming a nurse midwife in order to give your patients the SAFEST and best births, not simply the births "with the least interventions". If an intervention is indicated, you should be using it. I hope what you meant was "the sensible use of interventions"."
Yes Anonymous - I meant the sensible use of interventions. I do not always fully articulate what I am trying to convey.
I had real problems with vomiting during my labor with my son. I couldn't keep anything down. IV glucose might have really helped with my energy level during that very long labor.
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