Case Study on Continuous Support During Birth

Most recently I was contacted by a mother to be who was interested in having a doula at her birth.  She was very excited to have a natural childbirth because she had heard about horror stories when women went into labor and their doctor rushed them through the delivery.  Much to her disatisfaction, she was told that she could not have a doula and her family in the room at the time of delivery, she had to make a choice because the doctor did not want that many people watching.  I let her know that the choice was ultimately hers as we are not friends or family but we are part of the medical team helping the moms to be through labor and delivery.  She decided that she would go with her family in the room and hope for the best.

Delivery day came and she was very excited to give birth, what she did not anticipate was being in labor for almost 2 days with a failure to progress.  She received her epidural the minute that she arrived there and she thought surely she would deliver within a few short hours.  Well, she notes that was not the case after she failed to progress.  The Epidural slowed the labor down and because she was bed bound, she was not able to put all the labor tips into action to help herself along.  She ended up with a C-section for failure to progress.  The good part is that both mom and baby are doing great, the sad part as she put it was that she was never given an opportunity to try to birth her baby naturally before she was offered an epidural the minute she walked in the door.

The benefits of having a doula documented by the 2017 Cochrane Review indicated that having continuous support for women during childbirth, showed positive outcomes when a doula was part of the birth team.  When a doula is present, it decreases the chances of having pain medications, c sections, and it helps the mother have a positive birth experience that she will remember for life.

Here is the study that was done by the Cochrane Review https://www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth

  • Review: 26 studies on the effectiveness of continuous support during labor, which can include doula assistance. The studies included more than 15,000 women from a variety of backgrounds and circumstances.
  • Results: “Continuous support during labor may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labor, and decreased cesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score, and negative feelings about childbirth experiences. We found no evidence of harms of continuous labor support.”
  • Quick birth terminology lesson: “Analgesia” refers to pain medication and “Apgar score” is how babies’ health is assessed at birth and shortly afterward — the higher the score, the better.The researchers also looked to see if the type of support made a difference. They wanted to know—does it matter who birthing persons choose for continuous support? Does it matter if they choose a midwife, doula, or partner for continuous support? The researchers were able to look at this question for six outcomes: use of any pain medication, use of Pitocin during labor, spontaneous vaginal birth, Cesarean, admission to special care nursery after birth, and negative birth experiences.For two of these outcomes (designated with asterisks*), the best results occurred when a birthing person had continuous labor support from a doula– someone who was NOT a staff member at the hospital and who was NOT part of their social network. The researchers found that overall, people who have continuous support during childbirth experience a:
    • 25% decrease in the risk of Cesarean; the largest effect was seen with a doula (39% decrease)*
    • 8% increase in the likelihood of a spontaneous vaginal birth; the largest effect was seen with a doula (15% increase)*
    • 10% decrease in the use of any medications for pain relief; the type of person providing continuous support did not make a difference
    • Shorter labors by 41 minutes on average; there is no data on if the type of person providing continuous support makes a difference
    • 38% decrease in the baby’s risk of a low five minute Apgar score; there is no data on if the type of person providing continuous support makes a difference
    • 31% decrease in the risk of being dissatisfied with the birth experience; mothers’ risk of being dissatisfied with the birth experience was reduced with continuous support provided by a doula or someone in their social network (family or friend), but not hospital staff

    The rate of special care nursery admissions was no different between people who received continuous support and those who received usual care. The rate of Pitocin was also no different but there was a trend towards more Pitocin with continuous support from hospital staff and less Pitocin with continuous support from a doula.

If you have questions about your birthing plan, contact us for a complimentary 20 minute call to discuss your concerns 407-760-1662 or email us at info@windermerebabyandfamily.com

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The Benefits of Hiring A Doula

Doulas provide emotional, physical, and educational support to expectant mothers during the labor process and postpartum.  The doula is professionally trained in childbirth with the purpose of helping women have safe, memorable experiences and empowering a birth the way the mother desires. The doula services begin typically a few months before the birth in order to establish a relationship with the expectant mother.  Having the relationship early allows the doula to answer any questions that the mother and father have prior to delivery, ease any anxiety, and assist in developing a birth plan. During labor, the doula will provide the mother with comfort measures, position changes, breathing techniques, and partner involvement in the birthing process.  A doula leads to a better birth outcome and helps to reduce complications for both mother and baby.    Doulas use touch and massage as a means to decrease stress and anxiety during labor.  They use the sound of their voice to have the mother focus during the difficult stages of labor allowing this moment to engage the birth partner on the focal point.

After the delivery, the doula will help the mother start the breastfeeding process and to enjoy “the golden hour” of bonding.
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Strategies on Cultural Competence

In my own nursing career as a supervisor for field case managers, I have encountered patients and staff that come from diverse cultures. Every two weeks, our entire region would participate in something called Grand Rounds.  During those rounds, our medical director would review four cases that had been submitted for evaluation and best treatment options.  My team consisted of different cultures.  We had some wonderful nurses from different Caribbean Islands, some of them had a very strong accent, but that did not stop them from providing good care.

During one of our grand rounds, the medical director selected two of my case managers to present their case.  This case was presented in our own team meeting and we thought it would be a great one to present.  The one case manager we will call her Ms. R. presented a case about a member that had too many cats in the home and she was having difficulty staffing the case with home health aides because no one wanted to go in the home with so many cats. The medical director gave his evaluation of the case and the case was closed with the new information for the nurse case manager to implement.

During a manager meeting with about six other managers, the topic of case presentations came up and how each team needed to submit two cases per week, even if they were not selected for grand rounds.  A manager from England, who spoke with an English accent, stated that my team presented a lot of cases all the time.  I  stated that our strategy in our team meeting was to bring two cases every week so that everyone had a chance to comment. It also served as a good practice for the nurse presenting the case if the member was selected for grand rounds.  The English nurse manager asked me how I even understood Ms. R. and a few other staff from the islands that I had.  I politely let her know that I did have a diverse team and every one of them was a great nurse and social worker and did their jobs quite well.  As for understanding them, I listened to what they were saying intently and I did not multitask when they were speaking so that I could capture every word they said. Her response was I am glad that they are on your team (Clark et al., 2011).

I did resign from this position and unfortunately, four of the team went to this one manager and the other nine went to someone else.  But of the four there was one that was from Haiti, one from Grenada, one from Puerto Rico, and the other one was African-American.  I heard from all four about the poor treatment they were receiving from this manager. Of I course could only listen since I no longer worked there, but this was a perfect example of how not all nurses follow the code of respect for other people’s cultures.

With patients, it is the same thing, as nurses,  we are not always going to understand what someone is saying whether it is a language barrier, dysphagia from a stroke, or dementia, but we need to read the body language.  We need to fine tune our ears to try to understand what the person is saying. Living in Florida I am exposed to many cultures.  I myself am of Hispanic descent and although born in the states, I understand the diverse cultures that are here.

In integrating health teachings, many materials are available in Spanish and Creole, for the ones that are not, the use of translation companies are available through hospitals or managed care companies to help with the teaching that will be offered to the patients.

References

Clark, L., Calvillo, E., De La Cruz, F., Fongwa, M., Kools, S., Lowe, J., & Mastel-Smith, B. (2011, May-June). Cultural Competencies for Graduate Nursing Education. Journal of Professional Nursing, 27(3), 133-139.

A Review of a Nurse’s Role

A nurse can play three different roles as part of an interprofessional team.  The three roles consist of a nurse, nurse leader, and nurse educator.   The inter-professionalism team consists of other healthcare workers as well, not just nurses (Sommerfeldt, 2013). However, as nurses, the roles can be at different levels depending on the patient’s condition.  At my previous job, I worked as a complex case manager.  The team consisted of registered nurses, social workers (masters prepared) behavioral health specialists, community health workers, and nutritionists.  The nurse case manager managed the patient but if there was an issue with the patient in the home setting that required community resources, the community health worker would be consulted to assist in those needs.  If the member had psychological issues or other financial issues that required the need of a social worker or behavioral health specialist this referral would be added as well.  There was collaboration on the plan of care and all participated because we all were looking at the patient as a whole, not just as the part that each discipline took care of.  If a member was not able to pay his light bill or water bill due to financial difficulties until those needs were met through resources, any teaching that the nurse would do would be in vain.  A person cannot focus on teaching for their health or anything else if their mind is on their current financial strain, not their medical condition. In this instance, the nurse is playing the role of the nurse leader.

When a patient is in the hospital a nurse can also play the role of a nurse that is doing dressing changes, medication administration, and other treatments.  The nurse’s role in the interprofessional team may consist of the doctor, physical therapist, and dietitian, this would be more medically involved because maybe the patient is recuperating from heart surgery and requires a lot of care initially.  The patient may be on a special cardiac diet, which can also be explained by the treating nurse, however in this instance, the member is starting something new, so a consult from the dietitian can help the patient understand the diet and the nurse can reinforce the teaching.

The nurse educator as part of the interdisciplinary team can be seen for example in a disease management setting.  This type of setting also has multiple specialties that can follow the patient.  In this instance, the nurse educator is educating the member on how to empower themselves and learn about managing their chronic disease by learning about taking their medications, following a diet and exercise program, learning to check their blood sugar, or blood pressure.  The nurse educator can document what the patient learned based on return demonstration in the plan of care.

All three roles bring value to the scenario that they are in because the nurse will be around the patient most of the time.  In each role, the nurse is responsible for all aspects of the patient’s care.  Regardless of which role the nurse is playing, working on an inter-professional team is a style of partnership that allows decision making to be collaborative (Sommerfeldt, 2013).  It takes many people to working together to get a patient discharged to his home.

 

References

Sommerfeldt, S. C. (2013, February 25 2013). Articulating Nursing in an Interpersonal World. Nurse Education in Practice, (13), 519. http://dx.doi.org/http://dx.doi.org/10.1016/j.nepr.2013.02.014

Feelings of Anxiety

Many times as I review situations I have been involved in or a colleague has been in, the problem is always about the anxiety of one department telling another what to do and who has more authority or say in the matter.  What I find to be helpful, is that when one department is going to do work in another department, the manager should be speaking with the other manager first.  This way the managers can discuss exactly what is happening and when, so that if there is a bad time and they are able to work around the job that needs to be done, it can be resolved before the workers come out.  Many times things are approached from one manager to another with anxiety because a situation has occurred (Miller et al., 2008).  There are issues with authority over which department has more control of a situation.  As I always say, one department is always a guest in another department’s meeting or space, if this respected, then the relationship can be a smooth one whenever work needs to be done.

References

Miller, K. L., Reeves, S., Zwarenstein, M., Beales, J. D., Kenaszchuk, C., & Conn, L. G. (2008, June 2). Nursing Emotion Work and Interprofessional Collaboration in General Internal Medicine Words: A Qualitative Study. Jan Original Research, 333-343.

Importance of Professional Communication

Professional communication is very important when we are dealing with a patient’s health.  In this virtual world that we live in where more and more people are working in the field and from home, it is important that we maintain a standard of etiquette when speaking with people via electronic mail and in person. Rapid responses without thinking about them first can come across incorrectly in person and in writing.

In every organization, there are communication barriers, but overcoming them is part of being professional and respectful of others’ opinion.  One barrier that is seen in managers, is the inability to show respect to other team members and allow a learning environment.  This is a prime example of a barrier in a learning environment that will hinder an employee’s growth and affect the quality of patient care (Rubenfeld & Scheffer, 2014).

As a former manager of a team of nurses and social workers, collaboration existed in my direct report team, and as a team, we functioned using critical thinking, interdisciplinary team approach and collaborated on cases together.  But in the big picture of corporate America under the manager that I reported to, this was not acceptable, it was a multidisciplinary team.  In this type of team, there is only individual thinking in the group, meaning their way and no other opinions.  The focus will be on tasks and check off systems regardless if it is feasible to do (Rubenfeld & Scheffer, 2014).

Nurses do have the ability to be leaders and educators of a system that will stimulate change if they are assertive. In order to make an impact, a good team of interprofessional people is needed (DeNisco & Barker, 2013).  At the end of the day, the patient is the one who counts and the reason why changes are necessary. If more companies were focused on having a management style that was transformational vs transactional, this would alleviate the unnecessary resignation of employees, corrective action plans, and disgruntled employees.

In our team, for instance, a good way that we used to incorporate learning weekly was having one person do a case study and they would team up with another person on the team to present the case study on a difficult patient.  During this time the team had the ability to comment on the case, make suggestions and also refer to our medical director for review.

There are many teaching and learning styles that we can use to teach patients. The important thing is that no matter what we feel is our way or learning, not everyone will learn the same way.  Therefore as the nurse, we need to explore what is that patient’s learning style and teach in that way.  Another assessment the nurse can make in the home care setting is the readiness to learn.  If a patient is having difficulty paying his electric bill, he may not listen to the teaching on a diabetic diet and the foods that he is to be eating or buying, because he may not have the resources to purchase them.

In conclusion, managers and leaders need to be able to figure out a way to engage their teams, show them respect, praise them for a job well done and be able to involve them in the overall goal as a team vs. a transactional leader that dictates and causes poor morale amongst the team.

 

References

DeNisco, S. M., & Barker, A. M. (Eds.). (2013). The slow march to professional practice. Advanced Practice Nursing (2nd  ed., pp. 6-17). [Vital Source Bookshelf].

Rubenfeld, M. G., & Scheffer, B. K. (2014). Critical Thinking TACTICS for Nurses:Achieving the IOM Competencies (3rd ed.). [Vital Source BookShelf]. Retrieved from http://online.vitalsource.com/books/9781284059571

When a Patient is in Pain

Have you ever thought about your patients in the hospital that are under severe pain?  When someone is in pain, the painful stimulation must be removed in order for them to function. In looking at the activities that we do on a daily basis like brushing our hair, getting dressed and many others, I can see how many would not be motivated because of the pain that they are in.  When physical therapy comes around, they at times lose their motivation because it is too painful.  But if we write the plan of care and recommend to the physician that they have medications given to the patient about 20-30 minutes before therapy, then the patient may be able to work through the therapy that may be painful otherwise.

Some patients who are being cared for in the home setting may have experienced an injury or disease process that prevents them from taking care of themselves and they get frustrated.  This is when we can show the patient ways to remain independent and give them choices when possible.  For instance what foods they like to eat within their diet or what days they want their bath. Everything depends on when they have the help available, but at least whenever they make a decision, we should give them that option.  We can help the patient have some decision making power (Alligood, 2013).

 

References

Alligood, M. (2013). Nursing Theorists and their Work (8th ed.). Retrieved from http://online.vitalsource.com/books/9780323091947