Labor and Delivery Care

A Practical Guide

Wayne R. Cohen, Emanuel A. Friedman

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9780470654590
• eBook ISBN: 9781119971542
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Labor and Delivery Care: A Practical Guide supports and reinforces the acquisition of the practical obstetric skills needed for aiding a successful birth.

Beginning with the most important element of successful labor care, communicating with the patient, the authors guide you through normal delivery routines and examination techniques. They then address the best approaches to the full range of challenges that can arise during labor and delivery. Throughout, the 15 chapters provide concise practical guidance with:

• algorithmic decision trees
• clinical management tips
• detailed drawings

Labor and Delivery Care: A Practical Guide provides a thorough tour-de-force of the practical obstetric skills needed for best and safest practice based on clinical experience and evidence.

CHAPTER 1

Communicating Effectively With Your Patient

Human labor and birth are remarkable events, imbued with wonder and beauty. They are, nevertheless, prone occasionally to challenges, infirmity, and even tragedy. Caring for women during these experiences is a remarkable privilege, often exhilarating, but not without its perils and trials. To meet the demands of this task as a labor attendant—whether obstetrician, family practitioner, midwife, or labor room nurse—you must be equipped with the necessary clinical skills, judgment, empathy, and emotional insight to deal with all possible events and outcomes. While many of the physiologic aspects of the birth process are familiar and predictable, each woman will experience them in her own way.

A woman’s emotional and physical response to her labor and delivery is conditioned by many factors. These include her cultural background, personality traits, religious beliefs, and other aspects of her personal psychosocial context and history. You may have little ability to influence these factors, but it is important for you to understand them and to recognize how they influence the patient’s expectations and coping mechanisms during times of stress. This insight should always inform the content and style of any communications you have with your patient.

Other influences on the parturient’s ability to contend with labor are under more direct control. These relate to her physical and emotional comfort during the process of labor and birth. In that respect, the approach of the obstetric team is of great importance and can make the difference between an experience marked by satisfaction and contentment (even if there have been complications) and one that leaves a residue of resentment, regret, unhappiness, and unanswered questions. Not every labor and delivery experience can be idyllic, comfortable, and unencumbered by complications or missteps. We should, nevertheless, always aspire to that goal. Patients do value our endeavor and attitude. They expect and deserve our best efforts, even when they occasionally do not succeed.

Special aspects of parturition

Labor and delivery can be extremely stressful for even the healthiest of women. It is a time when feelings of fragility, vulnerability, and defenselessness are common, as are apprehension and a sense of physical and emotional discomfort. The reasons for these feelings are obvious. Consider that the parturient is likely to be in unfamiliar surroundings. She is wearing a hospital garment that leaves her nearly naked. She is bombarded with attention, surrounded by strangers whom she has just met. This applies even if hospital personnel have properly introduced themselves, which is sometimes not the case. She may be besieged by nurses, students, residents, and laboratory technicians. All of them want things from her that she may be in no mood to provide. Labor, especially once contractions are strong and frequent, is physically and emotionally demanding. It is not, in short, the perfect context for thoughtful reflection and objective decision making.

Things happen unexpectedly during labor and may surprise even the best prepared patient. If you have not had the opportunity to get to know your patient during her prenatal course, your ability to address such events is especially challenged. This is becoming more of an issue as medicine moves to reduced work hours for physicians and the need for more frequent turnover of care to colleagues at personnel changes. It is a problem well recognized by nurses and other healthcare providers who have always worked in shifts, and one that requires the development of new skills to address well.

Much has changed in recent decades concerning the nature of the interaction between healthcare providers and patients. Previously, we (especially physicians) were considered omniscient leaders of the patient care team whose opinions and pronouncements were law, not to be questioned by professional subordinates nor, especially, by patients. That paternalism has given way to a more interactive collegiality that, ideally, values the feelings and opinions of all members of the healthcare team and of the patient. That approach has, in fact, been shown to improve patient safety. It certainly adds dignity and civility to the professional interactions that surround decision making during labor, and respects the needs and wishes of the parturient.

The value of prenatal care

One of the best places to begin to assuage anxiety provoked by labor is during your patient’s prenatal course. In addition to discussing what to expect during normal labor, it is important for you to talk to her about potential adversities, including cesarean or instrumental vaginal delivery or oxytocin administration, should the need arise. You should also address the possibility of shoulder dystocia as well as of postpartum hemorrhage. While some practitioners would prefer not to bring up such potential calamities because of their relative rarity, it is important for you to give your patient at least a general idea of what would be done if any of them should occur. With good communication skills you can accomplish this without alarming her.

Most important, prenatal care provides opportunities to forge a bond of trust with the patient. In that way you can learn to understand the nature of her fears, educate her about potential risks, and have her understand what to anticipate during her labor. She, in turn, will learn more about you and become comfortable with your communication style. Trust is vital because not every peril or need for intervention can be foreseen. When something unexpected does arise, it is the previously established trust and confidence in you as the practitioner that will help sustain the patient’s composure and equanimity.

Establishing trust can be elusive and difficult for the patient because it requires her to relax her defenses and accept some vulnerability. She is seldom able to give it lightly because it ultimately requires exposure of the most private domains of her mind and body. One of the great virtues of prenatal care that extends for so long over the course of pregnancy is that your repeated meetings and discussions with the patient will serve to enhance her security and facilitate rapport. Needless to say, standards of professionalism require that you honor complete confidentiality in this respect.

Sometimes you may be called upon to form a bond of trust with the patient in a very short period of time. This occurs when you are covering for another physician or midwife, or have taken over at the beginning of a shift, or are functioning strictly as an inpatient “laborist” with no prenatal care responsibilities. As difficult as that process may be for you, it is even more of a problem for the patient, whose anxiety may be heightened by an unfamiliar face and manner. Establishing instant faith in these settings is not easy, but you, with experience, will learn to do so with success.

The key to establishing rapport with your patient involves your clear demonstration of empathy, respect, confidence, and availability. Openly acknowledge that this is a difficult situation for you both, but that you are committed to her comfort and good care. Let her know that you have every confidence in your ability to help manage her labor, that you are interested in her opinions and expectations, and that you will make every effort to meet them. Be approachable and available to answer her questions and those of her companion. Solicit questions from the patient rather than waiting for her to raise them, and be sure she understands that you will take the time to address them. Every woman in labor should feel that she is the most important person in your world at that time. This is only appropriate, because you are indeed filling that role in hers.

Communication skills

Use your powers of observation

Understanding the patient’s needs and responding to her concerns require your rapt attention. It should be clear to her that you are interested in and concentrating on what she has to say. Listen carefully to her concerns and observe her body language as well. A great deal is conveyed by facial expressions and other forms of nonverbal communication. Interviewing the patient while focusing your eyes on the chart or computer screen can be perilous. Not only is your inattention an affront to the patient, but you may miss many vital clues to her medical condition and emotional state.

Try to avoid confrontational or judgmental interactions, even if the patient appears to be challenging you. Make the effort to understand what underlies her obdurate or hostile feelings. They are likely to have arisen out of fear, anxiety, frustration, personal conflicts, or other distress. Remember that your relationship with the patient is bidirectional, and learning to see things from her perspective is vital in developing good communication skills. Part of that process involves recognizing your own reactions to various kinds of patients, especially the difficult ones. Enhancing your sensitivity to the special emotional needs of every patient as a unique individual is crucial to your role as a complete healthcare provider.

With experience, you will learn to tailor the style and content of your discussions with a patient so as to provide a clear explanation of the situation in a manner appropriate to her ability to understand it. The content and nature of such discussions may vary depending upon the patient’s level of education, what you perceive as her style of emotional defense or adaptation, and her interest in participating in the process. It is, under all circumstances, your responsibility to ensure that the patient understands the clinical situation clearly. Remember that, while a patient’s level of education may influence her vocabulary or her scientific sophistication and comprehension, education does not necessarily correlate with intelligence. When you use appropriate language, patients of all educational levels can understand and make reasonable and informed decisions about even very complex clinical issues. This is a difficult skill, but one well worth cultivating.

Disclosure of adversity

One of the things we have learned from the medical malpractice thorn of the past few decades is that patients are often driven to sue because they feel they have been abandoned by their doctor or by the medical system at a time of exceptional vulnerability and need. The residual burden of anger or resentment that spawns a lawsuit is more often born of the desperation and frustration at having been left with doubt and suspicion rather than of a conviction that harm has occurred because of an error in management. Often the search for answers is initially more important to the plaintiff than financial compensation, but that goal becomes subsumed in the legal quagmire of a formally filed tort action.

You can dissipate many of these concerns by frank and open communication with your patient during labor and afterwards, regardless of the outcome. It is regrettable that this does not always occur, particularly when there have been complications—the very time when discussion is most important.

Good communication includes involvement of the patient and, when appropriate, her family in decision making. It is vital for you to explain what is happening at every step of the process, even if there are complications or uncertainty. To repeat, you should tailor the timing, content, and tenor of these discussions to each patient and situation. As a general guiding principle, full disclosure of events is almost always the best path. As noted, explanations need to be individualized to comport with the patient’s educational level, language abilities, and most importantly, her coping style.

Many of us who care for women through their pregnancies tend to be especially poor conveyers of bad news. Perhaps one thing that appeals to some of us is that the vast majority of our cases have happy outcomes. Students who are uncomfortable discussing grave complications or prognoses with patients may for that reason be attracted to obstetrics. This is understandable but unfortunate, as bad outcomes in obstetrics are experienced with singular pain and are given special significance by families. The primary source of such pain probably arises from primal psychological forces, and is aggravated because adverse results are uncommon and because expectations are high. Moreover, the grief-averse practitioner may have a tendency (real or simply perceived by the patient) to ignore the problem or, worse, to trivialize obstetric loss.

Some of us tend to dismiss fetal deaths, whether through early miscarriage or even late pregnancy stillbirth, as insignificant life losses because the patient has an opportunity to redress them with another (presumably more successful) pregnancy. This is a regrettable, self-serving, and ultimately destructive attitude that serves mainly to absolve us from dealing with the emotional consequences of the loss. While the death or injury of a fetus is certainly felt and coped with differently than, say, the unexpected illness or death of a child or of an ailing aged parent, the loss of each may be felt with equal intensity. There is thus a special need for you to develop keen skills for communicating adversity. Fortunately, this can be learned, and practiced. It is an ability as important as communicating and sharing joy in response to a good outcome.

Dealing with family or companions

If your patient has a partner present during her labor, he can often be very helpful in providing emotional support and helping to communicate with you and the rest of the staff. Occasionally, however, the partner acts just like another patient, requiring his own support and reassurance. This may tax the patience of the staff. It will sometimes even divert personnel from their primary goal of serving the parturient. Always discuss with the patient when she is alone what her desires are regarding the role of her labor companion. This discussion helps avoid ambiguity, conflict, and confusion later as the labor progresses.

Sometimes, a large cadre of family and friends is allowed or even encouraged to attend the birth, a norm in some cultures. Under these circumstances you must ensure that the patient’s best interests and wishes are fulfilled, regardless of who is present with her. It is also useful for you to set ground rules and expectations at the very outset. Determine with clarity directly from the patient whom she wants present in the room during the actual delivery. You should also come to an agreement with her in advance as to when and under what circumstances guests may be asked to leave. In the latter regard, the staff may sometimes have to serve as the patient’s strong advocates, even acting forcefully against the contrary wishes of the guests.

Maintaining patient confidentiality in the context of a busy labor unit, especially when there are friends or relatives in the room, can be difficult, but must be honored as a basic priority and right. Bring family members into the discussions only with the direct consent of the patient, and be sure to obt...

Table of contents

• Cover
• Contents
• Dedication
• Title
• Copyright
• Preface
• How to Use This Book
• Chapter 1: Communicating Effectively With Your Patient
• Chapter 2: Examining Your Patient
• Chapter 3: Normal Labor and Delivery
• Chapter 4: Evaluating the Pelvis
• Chapter 5: Diagnosing and Treating Dysfunctional Labor
• Chapter 6: Managing the Third Stage
• Chapter 7: Dealing with Malpositions and Deflexed Attitudes
• Chapter 8: Managing Breech Presentation and Transverse Lie
• Chapter 9: Avoiding and Managing Birth Canal Trauma
• Chapter 10: Inducing Labor
• Chapter 11: Cesarean Delivery
• Chapter 12: Delivering Twins
• Chapter 13: Managing Shoulder Dystocia
• Chapter 14: Using Forceps and the Vacuum Extractor
• Chapter 15: Obstetric Case Studies
• Answers to Obstetric Case Studies
• Glossary
• Index