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Re: New Series #1-Admission and NSVD of laboring patients From: richardc@bcm.tmc.edu Tue Dec 31 10:49:48 1996 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Myer S. Bornstein: "Re: PAP Smear after TAH" Previous message: jean cooper: "Adisson risk assessment" In reply to: Robert J. Woolley: "technical bulletins" Next in thread: Malcolm Griffiths: "Re: technical bulletins" At Tue, 31 Dec 1996, MBK80@aol.com wrote: >For the first case in the series, lets discuss the tests and supplies we use >as we care for the laboring patient. Lets assume for this case that the >result will be a NSVD. >1-Admission- Admission should be ordered when patients are in active labor. >Admission in the latent phase (<3cm) may result in prolonged labor, >unnecessary invasive procedures, higher c/s rates, and greater expense. I fully agree. Jarnigan's rule is "There is no such thing as 4 cm dilated. Either she is three and walks, or 5 and admitted." This helps when assessing for active labor, since Friedman's curve noted > 90% of active labor at 5 cm, but only 50% at four cm. > Admission of the patient with PROM at term may be deferred until the patient >goes into spontaneous labor (many clinicians will prefer to have a reactive >nst prior to allowing this patient to go home to await the onset of labor. I >dont want to get into a discussion here regarding this issue, the main point >is that just because PROM has occured, admission does not have to be >automatic. Our experience is quite favorable with conservative management >when appropriate with resultant lower cost and no increase in morbidity. Yes, >the B strep issue is a concern. The problem I have is when the nursing staff, when evaluating the patient, has already performed a ditital exam. At this point I feel that the infection risk has occured and would like delivery mechanisms initiated. This usually means induction and, if no delivery by 18 hours, use of antibiotic coverage for GBS. What are others doing in this situation. Despite inservice for the nursing staff, every so often these patients are digitally examined. > >Tests ordered- CBC -No more preps and enemas. U/A seems to be a waste of >money. The blood bank may accept a "tube to hold", without charge, to be >later used for a type and screen if needed. Of course this assumes routine >prenatal labs have been previously obtained (type rh, hbsag, rubella titer, >ab screen, sickle prep, hiv, rpr) Here in Texas it is a state law that all moms get HIV testing upon admission. I agree that repetition of RH, rubella, if immune, are a waste, but hepatitis and syphilis can be present even if negative at 28 weeks or at new ob. > >Monitors- as you deem necessary- Many hospitals now are on a case rate and >monitoring does not cost more, however, remember it "costs" the hospital to >use a monitor , for its monitor paper, fileing, nurse observers, etc. I think >we are all familiar with the literature on monitoring . Remember that >internal monitors are very expensive. agree > >IV's- are they really necessary in many laboring patients??Just food for >thought for those of you still using them routinely.Obviously, we are not >discussing those patients with epidurals, PCA's etc., but even those patients >requesting IV analgesia may ask not to be "tied" to an IV. Often we will use a heplock, started at time of the blood draw, so to have venous access in case of need. While I have delivered patients without IV access, it still makes me nervous. Plus, lots of these moms are dehydrated, so finding the access may be trouble at time of delivery, if not placed sooner, when you are faced with a brisk post partum bleed. > >Delivery- Remember that gases, and placental pathology are expensive. I know >of many that do these routinely. It is difficult to not be cost effective at >delivery.Its usually during labor that we consume so many expensive >resources. agree >Most of us are using a standard delivery pack. Food for thought- >did you ever look to see how much of the pack you don't use. Do you use >drapes??? Only because they are in the pack, and will be thrown out anyway, like the Norplant kits. I agree that five or six wound towels should do the trick. When doing a D&C I just use three towels, no leggings, and do not have an increase infection rate. The use of all these drapes is extreme, but I do like a landing place on the abdomen for the baby for just after the delivery, so mom can hold the baby. I also think that way too much betadine is use, as if the area will become, or will stay, sterile. Any thoughts on this? >We don't and it really isn't necessary. Certainly many hospitals >require docs and midwifes to gown and use protective shields. This is for >each to decide on for safety. Getting the L/D area to customize the delivery >set up based on what members of the dept. use might be helpful to reduce >costs. > >Post Partum- we dont do any labs unless a PPH is incurred. Analgesia per >patient request but certainly not a need for epidural narcotics. We have >found many of the typical epifoams, proctocreme and stool softeners are not >necessary. We stopped using them a few years ago. Liberal use of ice packs >and sitz baths after 24 hours works nicely. Discharge home any time after 8 >hours with good home support in a motivated, educated patient, to 24-48 >hours based on individual needs. For the most part we find our patients >wanting to leave after a 1 night stay. Many docs keep their patientsd 2 days >by routine , and this is expensive. Agree. Sometime I worry that I'll get introuble once the "law" mandates that patients can stay for 48 hours after an SVD, and I still send them home in 24 or less. Great start. Rick -- Rick Chudacoff, MD Baylor College of Medicine BaylorMedCare Houston, TX Next message: Myer S. Bornstein: "Re: PAP Smear after TAH" Previous message: jean cooper: "Adisson risk assessment" In reply to: Robert J. Woolley: "technical bulletins" Next in thread: Malcolm Griffiths: "Re: technical bulletins"

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