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Monday, September 20, 2010

A dying art

I found this link just recently and it really caused me to think about how this art is already dead in labor and delivery. The dying art of the physical exam.

Part of the reason it caught my attention was because my husband just recently pointed out to me that sometimes what I do is like an art. I had just told him about a mom I had taken care of that had come into the hospital with her bag of waters broken. At that point ,she was not contracting, but she was wanting to have a natural birth and did not want pitocin right away. After having experienced many women who are able to give birth in a timely manner after their water breaks and without pitocin ,I was willing to work with her ,but not sure if her physician would. So, I took my time with her iv and other initial assessments. She needed antibiotics, so I made sure I hung that first. All the time I was watching her and noticing that she was feeling more and more contractions and that they were getting stronger.

I did talk to her physician and told him she wanted to hold off on the pitocin. He agreed as long as her cervix was making adequate change. This usually means that it changes 1 cm in one hour. When I first checked her ,she was only 3 cm dilated. I knew she was just starting out in early labor ,but that once she got going, it could be fast. So.....I didn't check her the whole time I was getting her admitted, or her iv hung. I saw that her contractions were coming closer together and that she was having to work more through them. I knew something was happening by how she was behaving. Four hours later ,she was checked and then delivered within an hour after that...without pitocin.

The reason I mention this is because in most cases, this mom would have been checked every hour and may not have progressed adequatly to begin with ,then given pitocin. Or they may have looked at her labor pattern and deemed it inadquate to change the cervix because the contractions were not coming close enough together to begin with. I even had one nurse mention how stange it was that she delivered so fast with contractions so far apart.

The problem is, in the ob world,, the art of the physcial exam has been lost to us also. We go more by graphs and numbers than by what women are feeling or actually doing. I could tell the woman was progressing by how she was acting...I didn't need to check the cervix or see if her contraction pattern was "adequate" by the numbers. I also knew that early active labor takes longer than late active labor. Therefore, it may have taken her 2-4 hours to change 1 or 2 cm, and then go faster after that. I was content that her contractions were apparently getting closer together and changing in intensity.

There is an art to is much easier to pull up a graph or do the numbers and determine that someone is not progressing adequately. It takes much more skill to assess and watch a woman in labor to determine this. And that art is definately something that is pretty much gone.


Handsfullmom said...

You're so good at what you do. =)

Rachel said...

This was one of my better nights:) I often wish I was better:)

Orange Juice said...

beautiful. we love nurses like you Rachel!!

Enjoy Birth said...

That is wonderful. So very true. Sometimes we just need a little patience!

Rachel said...

Your right, patience is a huge thing:) What I find interesting about the whole patience thing though, is that sometimes you do need to act. And that's where the art comes in. As much as we like to think that we know everything in medicine, much of it is educated guess really it does boil down to the art of having patience and knowing when to act. I am still a baby in this process myself:)

Birth is a Journey: Does it have to be life changing?

  • One woman might have to climb on an overfilled boat, risking her life and nearly dying as she escapes over the ocean to come to this land. This experience could certainly be life altering. It may very well color the rest of her life, positively or negatively. (I overcame this amazing struggle and here I am triumphant! OR Holy crap, that was SO hard I don’t know if I can go on! By the way, neither response is “right”. No one would judge the woman with the 2nd response.)
  • One woman may buy an airplane ticket, sit on a comfortable 747 and fly to America with a nice smooth flight and landing. She is happy to be in America. Those welcoming her are glad she is here safe and sound. She may only travel by plane 2-4 times in her life, so it is pretty memorable. But the journey itself probably wouldn’t be life changing; it would simply be a journey.
  • One woman may learn to fly an ultra-light plane to lead a flock of geese into America teaching them to migrate. This experience could certainly be empowering and life altering.