I was just reading at Birth Sense about how we're becoming more and more high tech and less hands on with caring for pregnant women. Is hands on care becoming a dying art?
With increasing alarm, it feels like the technology and gadgets are slowly taking over. Fetal monitoring has advanced from intermittent auscultation with a fetoscope, to doppler, to external fetal monitoring, to internal fetal monitoring. Or a combination of the last two.
Cervical exams might be replaced by the new gadgets that are clipped to the cervix to gauge dilation, effacement, and station. (I could not imagine using these in labor, but no doubt: it will be coming to a hospital near you before you know it!)
Leopold's is a lost art on newer nurses. Why palpate a belly when you can get a quick ultrasound? We are just not palpating bellies for fetal parts and position anymore. (Well, not all of us! Some of us still use Leopold's on almost every pregnant belly.)
A new nurse recently was aghast at the idea of not starting an IV on a woman who comes in completely dilated and pushing. Why? She's having a baby, not having a medical emergency. If she hemorrhages, we're good at putting in IVs lickity split. Or if we can't get a line in, there is always metherine or pitocin IM. Or cytotec given rectally. I mean, really, people! Think outside of the box!
Woman comes in, 10 cm dilated, pushing, delivering her baby within the next few minutes. ---> What are your priorities?
-Allergies to medication? Good to know this info.
-GBS status is moot. She's delivering.
-Is she term or preterm? (Do we need to have NICU ready?)
-Membranes ruptured? Clear fluid? (Mec??)
-Who is her provider? Is he/she readily available to come catch the baby, or will it be an RN catch?
-Auscultate fetal heart tones, if possible.
Slap on some gloves and prepare to catch the baby. Simple, really.
That is it folks.
11 comments:
When you open your birth center, I want to come work there. I also work with people who just can't imagine letting someone deliver without an IV - OMG, the world will end without IV access! Some people forget women have been doing this for years...many many years without EFMs, IV's, etc.
I haven't heard about the new gadgets that can be clipped to the woman's cervix! Why in the world is THAT necessary?
I saw a new ob pt yesterday that transferred at 31 wks EGA because not once had her first doc even measured her abd. She had her pap, and all tummy checks done by the nurse practicioner. Nothing wrong with that but she wanted her delivering provider to be more hands on. Not one of the recent residents rotating with me has even gotten close to the delivery weight with Leopolds. Hands on doctoring is a dying art also.
Too much reliance on technology = loss of the hands on skills. Very, very sad.
Like I said, I try to do Leopold's on every pregnant belly. After 9+ years, I'm getting better, but I still have so much room to grow.
I love how you say "catch" instead of "deliver"! :)
Only one doctor at the practice I went to gave me a size and position estimate by feeling my belly, and he was right on when I gave birth 4 weeks later. He also ended up being the one that was on call when she was born, and he was nice enough to stay really hands off and let me pull her out and up myself :) He was definitely one of the older docs in the practice. I liked him.
"Leopold's is a lost art on newer nurses. Why palpate a belly when you can get a quick ultrasound?"
Our midwives were better in guessing the baby´s weight than the OBGYN with his ultrasound. They´re equally good on determining the baby´s position.
Even if results are equally good, Leopold´s should be a MUST for all docs and midwives. It can always happen that you´re around a pregnant lady without an ultrasound device, but you´ll always have your hands with you!
I always wonder what these people would do in an earthquake or hurricane or terrorist situation when the power's out for days or weeks. We take too much for granted.
Personally,as an OB RN, if the pregnancy isn't high risk, keep the machines off, IVs (that includes saline locks too!)away and let moms do as they please. Ultrasounds aren't without their risks either...it has been shown that babies in utero try to move away from the line of u/s. Also VEs should be kept to a minimum during labor. High tech in no way substitutes for human touch, and I am glad that our province is moving in that lower tech/more hands on direction.
Well, I began working in OB before the invention of both the fetal monitor and ultrasound. What often gets overlooked is that there's a fine line between the SENSIBLE use of technology, and minimal or maximal use of it. Abdominal palpation is useful but has its limits; but I can say the same thing about ultrasound --one technique complements the other, not replaces it. Fetal monitoring has its place, too, but what I often see is the apparent need to have documentation at all costs, and to base decisions on it instead of using it as one technique among many to be weighed when making decisions. A lot of skills have gone out the window, since I began practicing, and some, like mid-forceps, I'm glad to have seen the last of. But I do wonder, sometimes, what folks will do if there's a power failure...
If you haven't read Jennifer Block's book "Pushed" before, I highly recommend it. It's a treatise on modern maternity care in the US - very thought-provoking. In the first chapter she describes precisely that situation: In 2004 when Hurricane Charley knocked out power for a week in Broward County, FL the L&D nurses at the county hospital got to spend a week watching unmedicated, non-interventive births. Emergency procedures were only used for genuine emergencies, of which there were very, very few. Most of them had NEVER seen a woman labor unhindered before. In the end, their stats for moms and babies were so good that the nurses began advocating for less intervention and more patient-centered care in their system. No one would listen and the hospital continued the same as ever with its nearly 40% c/s rate. Within a year all but one of the nurses from that week had quit L&D out of dissillutionment.
Oh, I am one of those people that arrived at the hospital at 10cm and pushing... One nurse tried (and failed) to start an IV- I was too wiggly and frankly would have punched anyone who stuck me with a needle at that moment. Another nurse said, "Oh honey, you can't push until I check your dilation!" and then attempted a VE, but what she found was my son's head crowning. It's been 5 1/2 years and I still look back and think, "geez, what moronic slaves to routine." Well, I think other things too, but most not fit for publication. My subsequent births were out of hospital.
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