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Discussion Starter · #1 ·
There are a few things are our local hospital that drive me nuts:

1. If there's ANY mec in the amniotic fluid, the NICU team has to come in for the birth and assess the baby immediately. Assess = tons of suctioning, and usually bagging. The docs and CNMs also suction on the perineum, whether there's mec or not.

2. All the docs give pit for the third stage, before the placenta is out. Also, they tug the cord to get the placenta out (makes me twitch).

3. If baby's temp is "off," baby goes in a warmer -- they don't do skin-to-skin til baby's temp is "right."

4. In general, cord is cut immediately and baby is whisked to the other side of the room to be assessed and cleaned and measured and weighed, before mom can hold him or her.
 

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As a member of the annoying NICU team


#1 Depends on the facility-where I work now, we're just called for thick mec. AT my former hospital, we went for any mec.
I do suction for mec with a bulb because mec is a wonderful growth medium for e.coli. And it's full of digestive enzymes that you don't really want hanging around in your nose (well, I wouldn't want it hanging around in MY nose)
:
Our doc's try not to suction on the perineum per new NRP guidelines but I think old habits are hard to break.
Why on earth would they bag for mec? That doesn't make a lick of sense unless the baby is in respiratory distress.

#2 Most of our babies are placed on mom right away (both mine were at a completely different hospital). If they appear to be in some distress, they are brought to the warmer so we can assess them/ intervene if necessary.

#3 I don't know about tugging on the cord. Some do, I know, but there are sooooooo many different people attending births, there isn't *one standard way* they do anything. Usually, if I'm there, I've involved with baby and not paying too much attention to the placenta-though I think they're really cool.

#4 Some docs leave the cord intact for a while (though less than a minute I'd say) SOme cut it immediately. Just depends on who it is.

There you go. That's my experience. I just started at a new hospital so it will be interesting to see what they do.
 

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I'm a new RN in a L&D dept (come from a homebirth background though). The hospital I work at is a rural hospital (at least thats what its considered- no NICU, no births under 34 weeks, etc.) There are lots of annoying protocols and it does totally depend on the provider:

-Continuous EFHM is pretty standard unless: the mother is not having any interventions (no pit, epi, low risk) and they know to ask to get the monitor off. For example, I know that protocol is a reactive strip on admission so I take them off after that if by some very small chance they are not being induced or getting an epidural (very small chance).

-Purple pushing. I don't unless the doctor is in the room and makes me.

-Doctor not to be called to the birth until head is crowning.

-Clear liquid diet.

-Immediate cutting of cord. Baby is put on mom's chest momentarily and I let stay there if there is not repair needed. If there is a repair the doctor makes me move the baby to warmer.

-baby is taken to nursery after 2 hours and stays there for about 2 hours doing stupid admission stuff.

I can think of more, but thats what I can think of now. Almost everyone gets Pit unless they come in cookin' with gas!

Jess
 

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That hospital sounds terrible! "My" hospital isn't anything like that. Mine is more like like BugMacGees. But my hospital is smaller. We don't have a NICU, we only have 3 delivery docs, and there are only 8 RN's and we rotate and there are rarely more than one of us on at a time.

Usually our docs stick around during labor. We have rules and protocols but we are very lenient and let the patient pretty much decide what they want during labor, delivery and PP. If there are problems/complications then we/the doc decides instead of the patient. We don't deliver here (on purpose) before 36 weeks because we are an hours medflight to the nearest NICU.
 

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I practice in a small, rural hospital. We are a Level II nursery, so no intentional births under 34 weeks, or newborns with known congenital anomalies, etc.

I can speak both to my own protocols, and to what generally happens with other providers in my hospital

1. I do not suction routinely, mec or no mec. Baby goes on mom's abdomen, or to her arms at birth (many of my clients birth squatting or hands and knees, and they would then scoop the baby up when they are ready) I suction only if baby is not vigorous with mec staining, per new NRP guidelines. I haven't actually suctioned a baby in, like, a year I think. I occasionally will slide the bulb into the cheek of a baby with a lot of secretions and suck that out, but not touching baby's sensitive palate or throat at all.
At my hospital, a few providers suction on the perineum, the rest do as I do. The nurses do not routinely suction, either. No NICU at my hospital, so no NICU team comes. The nurses are all trained in NRP and are the standard provider of resuscitation for any compromised newborns. All the docs are NRP trained, too, but generally only the 3 family docs who also deliver would get involved in a resuscitation, the rest of the time the nurse handles it and calls the pediatrician as needed.

2. We don't do active management of 3rd stage, so no pitocin prior to placenta. It is a hospital policy to give pit after delivery of placenta, so even I do it routinely unless mama declines, which happens now and again. I don't start IVs routinely unless mom wants pain meds, so I give pit IM if there is no IV. My routine for third stage is generally that I give baby to mom, or mom picks the baby up on her own, and we all wait. Mom and dad enjoy the baby, the nurses and I step back and are observers as long as baby is transitioning fine. In my experience, after a few minutes (10-15-20 minutes sometimes) mom will move from being engrossed in her baby to saying that she's feeling crampy, or say something about getting the placenta out. Usually by now the cord is limp, and if it is I clamp it for dad or whoever to cut, and mom is usually ready to push the placenta out on her own. I sometimes use a little gentle cord traction because sometimes the placenta is already detached but still inside.

3. We routinely use skin to skin for cool babies. Except believe it or not, I can't always get moms to agree, in which case baby goes to warmer. Even babies with TTN (rapid breathing shortly after birth, with good oxygen levels) go to mom for skin to skin. My standard orders, though, are that no one but mom can hold the baby if the baby is cold or having breathing issues, or whatever, and if mom isn't willing baby comes to nursery to be in the warmer. I'll make exceptions for dad if mom is ill, or unable to hold the baby - but no passing the stressed/cold baby around, not even grandparents. I have great luck with using mom as the warmer and try to whenever possible.

4. See other points. No immediate cutting, and no baby going anywhere. If I need to do a repair, I do it with babe in mom's arms, also, unless mom wants to put the baby down while getting repaired.

I forget about other hospital protocols practicing in my little corner of the world, where I personally have so much say in how things are done!
 

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Mmmmmmm. Well. I've attended births at...8 different hospitals, and I'd say five of those eight have between large and HUGE birthing units. My favorite hospital based birth place is an alternative birthing center with a regular L&D down the hall. THAT L&D happens to be the worst I've ever worked on, simply, I believe because the nurses try to "make up" for the fact that the ABC is in the same hospital!

Except for midwife attended births at two hospitals I attend at (including the MW's who catch at the ABC), they're pretty much what I now comprehend to be "normal" michigan birthing units. Granted, I usually enter the unit with a VERY in labor mama if I possibly can. Too, the mothers almost always have a birth plan, and...oh, I'd say that 99.9% of my clients are planning a no to low intervention birth (though her choice of birth place often precludes said plans, but I can't save them, they need to make their own choice). What do they get? Unless they or their partner are very vocal (or proactive and simply take it off when the 20 min strip has successfully been printed), constant EFM (nurses make it very clear that they're not "allowed" to listen to the doula, the words MUST come from the laboring woman") is the first place they start. If we come in at four or fewer centimeters, pitocin is almost gauranteed...I shoot for six to complete, for that reason, and thank goodness, it doesn't happen very often that I miss and we get there too soon.

At the birth, we literally have to physically keep some staff from taking healthy babies from mothers' chests before the mother is ready to give the baby up to be weighed. Little, quiet gestures, such as covering them both with a warmed blanket immediately after the birth helps...it's a visual and physical barrier.

The cord has been cut immediately in every single OB birth I've attended. One minute is a very long time for the OBs to wait. In one situation, the client had several conversations with the OB about delayed cord cutting, and said to me that the OB was totally up with their request, saying that she'd wait three minutes (!) to cut the cord. Fast forward to cesarean from maternal exaustion(baby's head was acynclitic and transverse). Doc cuts the cord immediately, of course--it's a cesarean now. Baby ends up in an oxygen tent for three days because her lungs wouldn't inflate, and then when they did, one collapsed.

If mom needs to be stitched, the doc insists that baby be taken away from mom.

At one hospital, baths are mandatory for baby. (what?!) Mandatory.

At another, if you refuse eye goop, CPS is called and a file is started. Yes, really.

At another, the nurses are so sure that first time mothers have no clue about their body that I have had clients (yes, plural) say that they are pushing to have the nurses say that it can't possibly be time to push, and then have the baby crown with no attendants at all in the room...and one come in grunt pushing and have the nurse tell her to calm down and be quiet, so that they could "assess whether she's even in labor or not." *sigh*

So...is this really the state of childbirth? I think so.

Every once in a while, we meet a wonderful nurse or an unusually and helpful and THINKING OB, and those are the days at work to be cherished. My goal, regardless of SOP or cranky staff, is to get the laboring woman her optimal birth if it's at all possible. It can sure be a lot of work! But boy, do I love my job.
 

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Quote:

Originally Posted by YumaDoula View Post
There are a few things are our local hospital that drive me nuts:

1. If there's ANY mec in the amniotic fluid, the NICU team has to come in for the birth and assess the baby immediately. Assess = tons of suctioning, and usually bagging. The docs and CNMs also suction on the perineum, whether there's mec or not.

2. All the docs give pit for the third stage, before the placenta is out. Also, they tug the cord to get the placenta out (makes me twitch).

3. If baby's temp is "off," baby goes in a warmer -- they don't do skin-to-skin til baby's temp is "right."

4. In general, cord is cut immediately and baby is whisked to the other side of the room to be assessed and cleaned and measured and weighed, before mom can hold him or her.
I can tell you what I do. I have a pretty high epidural rate (not by my choice) - I do births for other practices around the area with women that I do not see for prenatal care, so that plays in there. Some women come to my hospital because we offer epidurals. (Rural area - we are the regional referral hospital).

Here, NICU is called for pretty much all mec. I still try to transition on the mom's abdomen. If baby looks OK, they stay there. If they look like they are having a hard time, then they usually get swiped away by NICU. For thick mec, the NRP guidelines are to intubate and suction, so I have a hard time keeping those babies with mom. I do NOT suction on the perineum mec or not, and I am trying to educate those around me that the new guidelines say not to suction on the perineum. I try not to suction normal newborns at all, which has raised some eyebrows.

I only give pit after the placenta is out, unless it is someone with a history of significant postpartum hemorrhage, in which case I will discuss active management of third stage with women. Don't often do active management. I also have people who decline pit altogether, and that is fine. I only "tug" on the cord if I can feel the placenta sitting in the vagina and mom can't push it out. Many women who have epidurals will need directed pushing and a little help to birth the placenta because of the lack of gravity assistance.

I do skin to skin as much as possible. I do have a few women who really want the baby cleaned up asap, and I respect their wishes. Usually the nursery nurse does not come to weigh/measure/give meds for a half-hour to an hour after delivery. That helps. I do repairs with mom holding baby.

I do delayed cord clamping as much as I can, unless NICU is really breathing down my neck. With normal babies, it does help keep the baby and mom together
My population needs as much help with preventing anemia as they can get. It's been a little bit of a struggle, though, people have really questioned me about it.
 

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I shoot for six to complete said:
As a newly practicing doula, I'm not very confident in my ability to judge this.... The question comes up in class often, too. How, really do you know when to go to the hospital? The 4-1-1 rule really doesn't seem very realistic, especially for first time moms. Can you offer any insights into this?

(My apologies to the OP, don't mean to take over the thread...if you want, I can start a new one, but I would like to hear different views on the "when to go to the hospital" question. )
 

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Discussion Starter · #11 ·
Well as a doula, it's a catch-22 because our job is to support the mom, and if mom feels more comfortable being at the hospital, then I have to support that, even if I feel she's only in very early labor.

Most of the time, if mom is able to talk at all, it's too early. Plus, even when I've thought mom was a good 4-6, sometimes (often) walking into the hospital literally closes down the cervix. I had a client who was puking, not speaking btw ctx, moaning during ctx, and feeling pressure, and I thought she was probably in transition. She got to triage and was at ONE CM!
: It took about 2h after she got into a room for her to get back into a good rhythm, and that was with a lot of visualization and support. So I'm never surprised at dialation anymore, and I try to remind my clients that station and effacement is also really important.
 

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Ooh, also standard: threats and coercion. If you don't take the antibiotics your baby might die. If you don't take the Pitocin your uterus will give out and you'll have to have a c-section. If you don't take the c-section your baby will die. It's insanely common.
 

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Discussion Starter · #14 ·
Right, supine position is also the norm -- even if mom has no meds. I had a nurse tell a client that the baby wouldn't be able to get under her pubic bone if she was pushing in a side-lying position. So funny, because *I* was able to get my 8lb4oz baby out while pushing side-lying. I must have a really mushy pubic bone.
 

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FYI-

ACOG just came out with a new statement this month recommending against routine suctioning if mecomium is present. And I quote...

The Committee on Obstetric Practice agrees with the recommendation of the American Academy of Pediatrics and the American Heart Association that all infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning. If meconium is present and the newborn is depressed, the clinician should intubate the trachea and suction meconium or other aspirated material from beneath the glottis. If the newborn is vigorous, defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more likely to occur when attempting to intubate a vigorous newborn.


And there was a study published last year in the Lancet conducted at UC Davis that found benefit to infant iron levels with delayed cord cord cutting.

http://www.news.ucdavis.edu/search/n....lasso?id=7729

: my dd asked for this smiley, I'm not really mad.
 

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Quote:

Originally Posted by YumaDoula View Post
Right, supine position is also the norm -- even if mom has no meds. I had a nurse tell a client that the baby wouldn't be able to get under her pubic bone if she was pushing in a side-lying position. So funny, because *I* was able to get my 8lb4oz baby out while pushing side-lying. I must have a really mushy pubic bone.
This happens ALL the time.
 
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