Difficult questions
Dec. 30th, 2020 02:08 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
whitewriterThe textbook has a reflective thinking exercise question:
Karen is expecting her second baby and is now a week past her due date (so 41+0). She had a long labour with her first baby and ha dan epidural and a forceps delivery. Although this pregnancy is normal she has become increasingly anxious about the birth, and when you visit her she states that she wants an induction and another epidural as she has heard that babies sometimes die when they are overdue. How do you manage these concerns and how do you negotiate and support Karen's final decision?
I would begin by making a few gentle inquiries (provided this hasn't already happened in the visit) as to baby's movements for the last day or so, if she's been happy with the movements, or have been concerns about it being less or reduced.
Provided these have been normal and with no concern, I'd validate her fear by saying that death in utero is a common concern among women, and whilst it is increased in postdates the increase is marginal; that is an increase from 0.9 to 1.4/1000.
Considering that she is low risk (I'm assuming no gestational diabetes, normal weight gain, not of advanced maternal age, and NVB pre pregnancy) pregnancy that there is no reason to assume that her risk for the fetus and complication during labour be any higher should the pregnancy continue, rather than have an induction. That local policy states we wouldn't let it go past 42+0. She is only 7 days away from that.
I'd support that consering she is at 41+0, and is keen for an induction, that we can commence the process to ensure the cervix is ripe.
I'd explain the process:
1. post dates examination: CTG, observation, vaginal examination with optional stretch and sweep, and then :
2. returning the next day for a foleys catheter insertion : so that is CTG pre- foleys, VE to determine if the foleys is still required, then a post CTG to ensure the baby wasn't too stressed out by the foleys being inserted.
3. induction booking for the next day.
Such that it is a 3 day process; and if at any time during those days she goes into labour, that we would continue to support her through that process without the means of a foleys catheter.
In terms of pain relief options, I'd explain that there are multiple options that she's no doubt tried in her first labour. That as a multip with experience that if she is keen for an epidural to assist her with pain relief in labour that that's her choice. That there may be a delay in receiving it that is out of the control of the midwife - (like if the anaesthetist is in theaters or there are multiple women waiting for epidurals) - but we would endeavour to get her an epidural if that's her wish.
(now I wonder if the textbook is going to suggest i bring up the correlation between forceps delivery and use of epidural however according to a meta analysis 2018 quoted in up to date, this has not been correlated since the reduction in strength of epidural medications in more recent protocols which enables women to feel "more" during 2nd stage)
Honestly that's what I would say. I can't think of anything else.
This is real clinical life. The study does not stop when you get your degree or registration.
Karen is expecting her second baby and is now a week past her due date (so 41+0). She had a long labour with her first baby and ha dan epidural and a forceps delivery. Although this pregnancy is normal she has become increasingly anxious about the birth, and when you visit her she states that she wants an induction and another epidural as she has heard that babies sometimes die when they are overdue. How do you manage these concerns and how do you negotiate and support Karen's final decision?
I would begin by making a few gentle inquiries (provided this hasn't already happened in the visit) as to baby's movements for the last day or so, if she's been happy with the movements, or have been concerns about it being less or reduced.
Provided these have been normal and with no concern, I'd validate her fear by saying that death in utero is a common concern among women, and whilst it is increased in postdates the increase is marginal; that is an increase from 0.9 to 1.4/1000.
Considering that she is low risk (I'm assuming no gestational diabetes, normal weight gain, not of advanced maternal age, and NVB pre pregnancy) pregnancy that there is no reason to assume that her risk for the fetus and complication during labour be any higher should the pregnancy continue, rather than have an induction. That local policy states we wouldn't let it go past 42+0. She is only 7 days away from that.
I'd support that consering she is at 41+0, and is keen for an induction, that we can commence the process to ensure the cervix is ripe.
I'd explain the process:
1. post dates examination: CTG, observation, vaginal examination with optional stretch and sweep, and then :
2. returning the next day for a foleys catheter insertion : so that is CTG pre- foleys, VE to determine if the foleys is still required, then a post CTG to ensure the baby wasn't too stressed out by the foleys being inserted.
3. induction booking for the next day.
Such that it is a 3 day process; and if at any time during those days she goes into labour, that we would continue to support her through that process without the means of a foleys catheter.
In terms of pain relief options, I'd explain that there are multiple options that she's no doubt tried in her first labour. That as a multip with experience that if she is keen for an epidural to assist her with pain relief in labour that that's her choice. That there may be a delay in receiving it that is out of the control of the midwife - (like if the anaesthetist is in theaters or there are multiple women waiting for epidurals) - but we would endeavour to get her an epidural if that's her wish.
(now I wonder if the textbook is going to suggest i bring up the correlation between forceps delivery and use of epidural however according to a meta analysis 2018 quoted in up to date, this has not been correlated since the reduction in strength of epidural medications in more recent protocols which enables women to feel "more" during 2nd stage)
Honestly that's what I would say. I can't think of anything else.
This is real clinical life. The study does not stop when you get your degree or registration.
