Passive Descent vs Pushing in Second Stage of Labor

Most recently I was asked to comment on whether during the second stage of labor ( which is the onset of full cervical dilation) should be passive descent vs. pushing.  In my opinion, it all depends on what policy the treating practitioner uses.  I worked at a high level labor and delivery unit up North where women were flown in if it was an emergency or bad delivery anticipated or trauma.  But we also were a Catholic Hospital and took care of the indigent. We had a teen obstetrics clinic in the area (not related to the hospital) but it was across the street.  They handled all the teenage pregnancies that came through their doors.  It was managed by two very caring midwives.  At this clinic, the girls not only received prenatal care but they also received information on how to take care of their babies.  The girls were referred to pediatricians to get healthcare for the babies and to school counselors to help them get their GED’s.  But the best part was that these midwives taught natural childbirth at their clinic.  When a girl came into labor, they went into the birthing room and they did perineal massage to do natural descent.  They worked with the contractions.  These girls rarely had any perineal tears.

One day one of the midwives was on vacation and the other one was in the clinic and could not get there this one time and one of their girls came in almost completely dilated and effaced.  The resident on duty that evening was one of the most arrogant doctors I had ever seen, he had smart remarks before he even got in the room with her. He went inside to do her exam and he rammed into her and the girl nearly jumped three feet, I calmed her down as she was a scared 15-year-old girl.  She screamed and he said listen you had something much bigger in there than my finger, I quickly stated, doctor that is enough.  He said,  yes she is dilated,  get her in the delivery room, I said that the girls go to the birthing rooms and deliver there in a more holistic approach; his reply was, we don’t have time for that garbage, get her pushing and delivered.  This poor child gave birth and had tears from front to back, she was in such pain, as she could not have an epidural or pain meds since she was already effaced and 10 cm.  I did not have kids at that time, but could only imagine by the grips of my hand and the tears and screaming that she was suffering.  I was barely 21 years old.  The midwife came finally after she closed the clinic at 7pm to check on her patient and was so angry after the patient told her what happened. She brought up the incident to the hospital administrator who placed the doctor on probation.  He had a few incidents with me and some other nurses and eventually was fired from the residency at that hospital. Knowing the hospital’s practice for each unit and also what the practitioner believes is very important (Denisco & Barker, 2012).  Some doctors will approach labor and delivery with a more holistic approach.  This would be an approach that Jean Watson’s theory on caring would fit in to.

 

 

References

Denisco, S. M., & Barker, A. M. (2012). 25. In Advanced practice nursing: Evolving rules for the transformation of the profession (2nd ed., pp. 547-567). Retrieved from https://campus.capella.edu/web/library/home

Evidence-Based Models and Practice Settings

One of the clinical problems that I see in the Neonatal Intensive Care Unit (NICU) is nurses and healthcare staff becoming complacent in their environments because it is a job and the passion is lost allowing the nurse to move through the motions.  We are all guilty in many professions, not just nursing, of treating people matter of fact and we forget it may be our hundredth experience, but it is their first experience, no matter what the experience is. When we approach any person, especially in our nursing experience, we have to approach them with kindness and passion. We as nurses cannot continue to eat our young (the new nurses coming to work) and continue to treat our patients as if we need to move on to our next task. Our body language, tone of voice and facial expressions give away our genuineness.  We are all busy, but we have to put that aside and go back to compassion and empathy, thinking about how we want to be treated in this situation if we were in it.  We have to utilize our critical thinking to see what level of care that parent needs to get through this situation at hand.

One problem that I see is infant readiness for oral feeding of the premature baby.  There are different opinions on the expertise of how it is done.  Being able to see the situation first hand as a mother and then being able to see it as a professional, made me aware of not only my actions but others around me.  My son was given breast milk initially via NG Tube until he was ready to try a bottle.  Initially, the bottle feeding was started once per day and increased and they would leave the bottle-feeding for when the parents were there to feed the baby to create that bonding experience.  One day I arrived at the NICU on a weekend ready to spend the entire day with my son and getting to feed him several times per day.  The shift nurse that I had never met said that I was feeding my son wrong.  She took over the feeding entirely and when the rest of the feedings occurred that day, she took over because she stated that I was making the baby aspirate due to my inexperience.  I was only allowed to hold him.  When the change of shift occurred, she said okay time to go, I stated that we were in a private room and the nurses close the door so that we do not have to leave during the change of shift.  We were in a private room because at one point the baby had developed a hospital-borne infection called Serratia and he had to remain there until discharge.   Staying in the room was an arrangement that I made with upper management due to the fact that I worked full time as did my husband and we did not have much visiting time with him during the week.  She proceeded about her business and ripped the baby right out of my arms.

I cried for days until Monday came and I made a complaint to my head nurse who assured me that this was documented in my chart right on the front. She showed me the chart and stated that she would speak to the nurse about her abruptness.  The weekend nurse assigned apologized to us a few days later, but by then my feelings were already crushed.   It was later discovered that the baby was aspirating even when he was fed via g-tube it had nothing to do with how I was holding or feeding him.  It was inevitable.  In the end, it was decided that the baby would have a Mickey G-tube inserted surgically for feedings to expedite his discharge home.

When discussing with peers, the Colorado model seemed appropriate because it has a patient-centered focus.  In the NICU, the focus is not only on the baby but the parents, they become your patients, too.  In this instance, the issue that I experienced was discussed and it came to be known, that yes, as nurses we can have the one-track mind of getting things done and checked off a list. There is a lot that happens in the NICU that is unexpected, so the less that can be focused on that is routine, the better.  Nurses can do things better, faster and with expertise, but is it really better?  Parents would say no because they are left out of the important equation in the Colorado model.  The Colorado model discusses that patients should have some control or personal choice in decision making, whether for personal preferences religious or cultural decisions (Goode, Fink, Krugman, Oman, & Traditi, 2010).

 

 

References

Goode, C. J., Fink, R. M., Krugman, M., Oman, K. S., & Traditi, L. K. (2010, August 10). The Colorado patient-centered interprofessional evidence-based practice model: A framework for transformation. Worldviews on Evidence-Based Nursing, 96-105.