Week Five
Choose one of the following activites and respond here:
- Watch the documentary, the Business of Being Born (I have a copy to borrow) and comment on the film then discuss the differences between homebirth, hospital birth and birth in a birth center. Also discuss the difference in training, certification and practice of the Certified Professional Midwife, Certified Midwife and Certified Nurse-Midwife. See http://www.thebusinessofbeingborn.com/ for a preview and review of the film.
- Continuous epidural anesthesia is often adminstered with a Patient Controlled Device (PCA) allowing the patient to redose the epidural. Read the following exerpt from the Alabama Board of Nursing Standards of Nursing Practice: "The topical, intradermal, subcutaneous, or intramuscular administration of a local anesthetic agent in a specified amount designated by order of a licensed physician or dentist and in compliance with the FDA regulations may be performed by a licensed practical nurse or a registered nurse. The monitoring and adjustment of local anesthetic agent(s) infusing via an epidural, brachial plexus, or femoral catheter placed by a qualified certified registered nurse anesthetist or qualifed licensed physician may be perfomed by a registered nurse, with the use of an electronic pump or infusion reservoir, as ordered by a licensed physician in compliance with the FDA regulations and established nursing standards. The registered nurse is not authorized to administer bolus dosages."According to this document, can a RN push the PCA button for the patient? What might occur, legally, if the RN chooses to push the button? Describe what you would do if asked by the physician or your supervisor to push the PCA button for your patient?
- Read about this midwife who has a homebirth practice in Alabama. http://birthwithhope.com/aboutthemidwife.aspx. In Alabama, homebirth is illegal and therefore a Registered Nurse may not attend. Discuss your thoughts about this midwife's practice. What is her legal risk? What are your thoughts concerning her respresentation of the scope of practice of the Registered Nurse?
19 comments:
I watched "The Business of Being Born" and, although it seems slanted in favor of home births, it is very informative about the issues. Hospitals may not be the ideal birthing environment after all. We have already learned in class how important doulas are to childbirth. And this film spells out the subpar statistics in the US associated with hospital births. This goes hand in hand with the rest of the US's subpar performance in keeping people well. We're very good at "saving people from the edge" in the US, but we fall short when keeping people well. Throwing money at a problem is rarely the only and best solution. Considering this, a home birth with a nurse midwife and adequate prenatal care seems safe enough an option for a large majority of births. Using a nurse midwife seems like the best option, though, because an early assessment of a bad situation can make the difference between life and death. The film did not go into as much detail with certification of midwives as i would have liked. It also did not go into much detail about the nurse midwife's capabilities if something does go wrong. I wish they would have discussed what was in the nurse's "kit" more indepth, but I realize the target audience is not nurses. Overall, though, a compelling and informative film.
I decided to comment on the second actvity. The way I read the excerpt, a RN would not be allowed to push the PCA button because it would be considered a bolus. If the nurse pushed the PCA button, her or she could be held accountable for practicing outside his or her scope of practice. These charges could lead to suspension or revocation of her or her license. If my patient asked me to push their PCA button I would explain that I was not allowed to push it for them. I would then make sure they had no questions as to how to use the pump or what medication they were receiving from the pump. After that I would watch them use the pump and ensure it was being used correctly.
I chose the question about PCA pumps. An RN is not allowed in the state of Alabama to push the PCA button on an epidural to deliver a bolus. The RN is only allowed to monitor and adjust the epidural. If I was asked to push it by a supervisor or physician, I would explain to them that I cannot legally do that and it is out of my scope of practice. If I did choose to make the decision to deliver the bolus, I could lose my nursing license or the license could be suspended.
I chose to do the second question about the PCA pump. A nurse is not allowed to push the button on a PCA pump for a patient. This is not within a RN's scope of practice. If asked to deliver a bolus by the physician, I would have to explain to them that this is not within my scope of practice, and there could be serious consequences for doing so. The consequences could be suspension or loss of the nursing license. I would make sure the patient understood how to use the pump correctly and why it was being used.
I decided to complete activity three about the midwife who has an Alabama homebirth practice. Midwifery sounds like such a wonderful practice that focuses more on the patient and the birthing experience itself. Although, since homebirth is illegal in our state I don't think that it is such a wise thing to purposely go against the law. I tryed searching for legal risks and all I saw was that they will be persecuted and that they would be considered a criminal. There are alot of legalities also because during birth there are alot of unpredictable circumstances and risks were you wouldn't have the trained staff and equipment necessary if an emergency should arrise. I feel she is completely out of her scope of nursing practice and should maybe consider moving to another state until homebirths become legalized.
I visited the midwifes website and was reading about her practice. I thought it was very different then what goes on in the hosptial. I think that for healthy low risk moms having a midwife and giving birth in a much more comfortable atmosphere is a wonderful alterative. This midwife sounds credible and sounds like she has the experience necessary to deliver babies. I am skeptical as to why she would choose to practice even though it is illegal. If anything did go wrong during the birth and she was not able to resolve the problem, and the baby or the mom was injured it would fall on the midwife legally, especially if the problem could have been prevented had the mom been in the hospital. I think that Al should consider making midwifery legal, it is a very special field of practice.
I chose question number 2. If i was asked to push the button for the patient by a physician or other health care provider I would simply tell them that it is not in my scope of practice to administer a bolus to the patient and the patient must push the button on their own. I would tell them that by doing this I am putting my license in jeporady for being suspended or revoked. If that patient asked me to push the button I would simply tell them as well that I was not allowed within my scope of practice to do that for them, and I would educate them on how the machine works and what they would need to do to get their medication.
In my opinion, this excerpt(question #2) states that a RN or LPN can administer the pain medication, but she cannot push the button to deliver a bolus. The patient is responsible for pushing the button, and therefore, receiving more medication. The RN could lose her job and license if something were to happen and the patient received too much sedation. I would tell the doctor or my supervisor that I was not legally allowed to push the button for the patient. Since no one really knows the amount of pain another person is experiencing, it is not up to the RN to decide when to give more medicine in a PCA set-up. PCA means patient-controlled analgesia; it defeats the purpose of the idea if someone else pushes the button. The nurse’s role should be to educate the patient on how to use the pump and monitor vital signs, especially respirations, per protocol.
I decided to read about the midwife practice. The midwife seemed extremely qualified she had years and years of experience from women's health to NICU. The whole birthing process was about the comfort of the mother and a natural beautiful experience that the midwife had not seen in her many years of OB. All of the services she offered seemed to be outstanding. I do not understand why she practices in Alabama if she knows in it illegal because of all the consequences that could fall on her if something unexpected happened during one of these births. I think midwifery is an extremely exciting profession and believe that Alabama should think of all the benefits that would come along with it.
I chose question number two about the PCA pumps. An RN is not allowed to push the button as that is not in the scope of practice for an RN. If an RN did, there would be serious consequences such as suspension of his/her license. If a physician or patient asked me to push the PCA button, I would explain to them that is not within my scope of practice. I would also make sure the patient is able to push the button and is aware of how the machine works and how to use it.
I chose option # 3 in regard to the midwife practicing in Alabama. Although I agree with the ideas she is promoting - gentle, relaxed births in a setting that the mom chooses, she is jeopardizing her licsense by practicing in the state of Alabama.
Maybe she should devote more of her time lobbying the legislative process to benefit the practice of midwives in Alabama.
I chose exercise #2. In my interpretation of the excerpt, by pushing a patients PCA button for them not only are you our of your scope of practice, but you may be assaulting the patient. A registered nurse is not allowed to control the PCA pump for a patient since a bolus would be delievered. If asked to perform such a task by any member of hospital staff the registered nurse should refuse without hesitation. If the patient cannot push the button themselves, then the physician should be made aware and should adjust care accordingly.
My instinctive knee jerk reaction regarding deliveries by midwives is “Is this safe?” It seems to me that this midwife finds this to be a common reaction and addresses that concern right from the start by beginning her listing of credentials with her experience in the prestigious Hospital of the University of Pennsylvania’s “high tech facility” and her military service treating casualties. However, I couldn’t help but notice that she only “saw” anencephaly, twin births, triplet births, quadruplets, and many preterm babies. This is not the same thing as being specifically trained to anticipate and manage these conditions. Likewise, her military hospital experience is impressive but doesn’t specifically qualify her to manage obstetrical surgical emergencies, even with her experience in the recovery room.
I felt like this webpage advertised or promoted her services rather than gave an objective assessment of a prospective patient’s ability to have confidence in her care. Accordingly, I searched for some objective data and googled an informative article. Researchers from the School of Public Health in Brussels, Belgium presented their case for improving maternal mortality rates in developing countries. Their research is also applicable to the Unites States, especially in the current climate of health care reform.
In 1870 maternal mortality rates in Europe were above 600 per 100,000 live births. By the end of the 1960’s the rates in northern European countries had dropped to 10 per 100,000. The difference can be attributed to three factors: political commitment, availability of effective techniques such as asepsis, and assistance to most deliveries being provided by trained health professionals. In 1918 in the US, however, the maternal mortality ratio was 885 per 100,000 live-births, twice the Swedish ratio for the mid-19th century. The difference in rates is attributed to the difference in maternal care. While the northern European countries had a low proportion of instrumental deliveries and a high proportion of births assisted by well-trained midwives, the US authorities, both medical and governmental, favored having all women delivered in hospital attended by obstetricians.
In 1925 a pioneer, Mary Breckinridge, demonstrated that midwives providing care in the rural area of Kentucky resulted in a mortality ratio of 68 per 100,000, whereas the doctor-provided care in the town of Leamington resulted in a rate exceeding 800 per 100,000. A 1933 report by the Public Health Relations Committee of the New York Academy of Medicine showed that 61% of 1343 avoidable deaths could be attributed to the doctors (abuse of anaesthetics, unjustified instrumental deliveries – particularly caesarean sections –, etc.), while the behaviour of the midwives and women was held to be responsible for only 2% and 37% of these deaths, respectively. A number of similar investigations into maternal deaths came to the same conclusions. In the US, the medical lobby managed to hinder the development of professional midwifery outside the hospitals.
My reflections after reading this article are as follows: 1) Properly trained midwifery is not only safe but life-saving and cost-effective and should be encouraged and promoted in the US. 2) The politicians must be persuaded to end the medical establishment’s choke-hold on health care and the current legal restrictions on midwifery. 3) Nursing schools will provide necessary education for an advanced degree equivalent to Nurse Practitioner, as soon as it is legal to do so.
De Brouwere, V. D., Tonglet, R., & Van Lerberghe, W. (2002). Strategies for reducing maternal mortality in developing countries: What can we learn from the history of the industrialized West? [Electronic version]. Tropical medicine & international health. 3(10), 771-782.
Answering the question #2 As RN I would not be okay with pushing anesthesia medication. This would be out of my scope of practice and could put my job and license in jeopardy. I would explain the reason to the Dr and Patient of why i would am not willing to push. Also, i would explain to my patient the correct way of administration and when to know to do so.
I chose question number two. Based on my understanding of the document a RN in the state of Alabama is not permitted to push the PCA pump button for the patient because that would be delivering a bolus dose. The RN is allowed to manage the pump. If a doctor asked me to push the patient's PCA pump button I would explain to him that I am unable to do so because that is out of my scope of practice and did not want to jeopardize my patient or my license.
According to the article an RN can not push the PCA button because it would deliver a bolus to the patient. I understand there could be some severe legal ramifications if i were to comply with the doctor's request. If I were asked by a physician to push the button for a patient on a PCA pump I would let him know that i don't want to lose my liscense that i worked so hard for but i would speak with the patient and request for them to push their own PCA button... If they won't then they are obviously not in excrutiating pain at the moment... if they have a decreased LOC then they don't need to be sedated any more as it is!
I read about the midwife and she seems very educated and experienced in childbirth. She seems very adequate when it come to deliverying a baby but if there was a complication all fault would be on her. She could be prosecuted if the baby or mother were injured or died during labor. Especially if it could have been prevented with medical intervention. It is a risk for her to go against the law and continue to help deliver home births.
i am commenting on the mid-wife issue. I think that although this woman seems like a wonderfully trained nurse, I do not think that she should be putting her license on the line by using her nursing experience to advertise her midwifery when she is not formally trained to be a nursing midwife. Although I do admire her for her courage and passion for midwifery, I don't admire the way she practices out of the scope of her practice and puts her liscensure at risk.
I witnessed a nurse on the OB L&D floor push the button to deliver a bolus on th eepidural pump three times in a 45 minute period. I was concerned in regards to the actions of the nurse and I didn't know that this was not an exceptable behavior for an RN to do. The patient was feeling pressure from baby descent but had verbalized that she wasn't hurting that bad and didn't want to prolong the labor and wanted to tuff it out. The nurse didn't ask if she wanted a bolus of the epidural she just did it. I believe that it is of the upmost importance to know the extent of the nursing practice.
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