Refusal of a c-section

I see this many, many times -- dysfunctional labor with a posterior/asynclitic positioned baby. Labor drags on and on. Sometimes, the provider is relaxed enough to not jump the gun on calling a c-section for FTP, and "allows" the labor to continue.

Eventually, the woman gets to 10cm. Baby is still posterior/asynclitic. Urge to push commences, and the pushing stage begins. She pushes, pushes and pushes, and the baby barely budges.

Will the baby fit?

We change her position frequently to help facilitate rotation and descent.

Pushing continues.

There may or may not be some pitocin infusing. Most women have an epidural long before this point.

The doc comes in, tries a vacuum. It doesn't work. Doc recommends a c-section. The woman and her husband refuse the c-section. They would rather keep pushing and changing positions. (Thank goodness for a good nurse when this situation happens!)

Lo and behold, but what happens?

Most of the time, vaginal birth just isn't in the cards. Proceed to a c-section. Not always so........believe it or not, I've had some births that follow this exact same scenario, and after a failed use of a vacuum, the woman is able to push her baby out spontaneously.

Tearful cries of joy abound!!! The baby is here!! No shoulder dystocia, great apgars!! Baby lies skin to skin with mom, and nurses like a champ.

All in a day's work.

The debate rages: food vs fluids vs NPO

I was backing up a fellow RN on labor and delivery in her conversation with an OB resident about the other nurse's patient. The woman was having baby #4, she wasn't in labor yet, and they were unsuccessfully (thus far) inducing her labor. It was day #2 of her induction. Things were winding down for the night: everything for her induction was stopped.

What would you want to do, if it's been a two day process, so far, and you were pregnant? You'd want to be able to eat and drink, right? That was what this other nurse was advocating for her patient. Let her eat a light dinner, and let her rest for the night, before restarting her induction in the morning.

The OB resident (who I admit is still very green behind the gills) was arguing with the nurse about it -- saying no, this woman can just have ice chips and maybe a Popsicle or two. The doc was mumbling about aspiration risk, blah blah blah.

I piped in: well, since she's a G4 who has given birth vaginally before, just how do you think she's an aspiration risk? Chances are extremely low that she'll need a c/section, and even lower that she'll need general anesthesia for a c/section --- which is precisely where the "worry" for aspiration of stomach acid lies.

How many times do women need general anesthesia for a c/section? I can count on one hand per month how often that we do general anesthesia. How often are c/sections under dire emergency conditions requiring general anesthesia actually seen on labor and delivery? Even less than the one handed count of cases of G.A. we see per month.

This patient? Extremely low risk for G.A., much less the need for a c/section, even less of a chance of aspiration of stomach acid.

I argued the fact that aspirating pure stomach acid will actually do more damage versus aspirating fluid/food laced stomach contents, which will be less acidic.

Both of us nurses also brought up the fact that even ACOG recommends liberal fluid intake during labor ---- and this woman wasn't even in LABOR!!! So, you want to continue to starve her for another day, putting her body into a further ketotic state? (The resulting symptom is the lovely ketotic breath that laboring women in longer labor tend to get - the body isn't being nourished, so it starts burning it's sugar stores to maintain some kind of energy level --- and energy required for labor is higher than not being in labor.)

I brought up - how about practicing some evidence-based medicine here? Let the poor woman eat something light, if you're so worried. How about some chicken noodle soup and some saltines? Something to help hold her over, but yet makes her feel like she's actually "eating" something, versus a simple Popsicle?

In the end, the resident gave up arguing back with us, and told the nurse taking care of the patient to get the order if she wants it, from the attending MD about a light food diet for this non-laboring woman.

We're trying folks. We're trying hard (as nurses) to help the newer doctors see the light about evidenced-based practice. However, even when ACOG backs up our arguments, the doctors still refuse to listen.

Oh, and the NPO in the title of the post? That's one particular doctor who is notorious for making every single woman under his care NPO. Even when not in labor.