Tuesday, July 27, 2010
Bonding on the NOB
For those of you who know me, I'm pretty chatty. I tend to wear my emotions on my sleeves and I love to talk about babies. So you can imagine how exciting a new OB appt. is for me; and usually for the pt. I learned a tough lesson a few days ago on developing my style and relationship w/a patient, particularly during a new OB appt. (where I am meeting a new patient and have yet to establish a viable pregnancy). I performed the dating US on a G1P0 with her partner happily looking on. Thank God my preceptor was standing right next to me and immediately took over when we quickly realized there was no fetal heart movements. The way she handled this case of a missed abortion was compassionate. She told the couple the facts: there was no heartbeat and the baby had stopped growing sometime in the last week (by US, the fetus measured 9 weeks, 4 days and based on her LMP she would have been at 10 weeks). She presented her with all the options: do nothing; serial HCG and a repeat US in three days to confirm that there is no heartbeat- since we could be off on the due dates and maybe this was a 7 week pregnancy (highly doubtful); or D&C. Most importantly, she told them there was nothing they had done to cause this and that it happened in 20% of pregnancies. They chose to do the serum testing/repeat US. My preceptor said she did it so they could have time to process this event- it was the humane and right thing to do. It also taught me the value of not doing some of the education/bonding upfront, but waiting till the exam was finished. What if I had already started talking to her about whether she'd breastfeed the baby, or talked to her about what whether they wanted a boy or girl (things I have done on a NOB visit). You have to draw a fine line at some point- and this is unnatural to me. I don't like being cold and matter of fact: I always said that's why I became a nurse, and not a physician. But as a provider, this would not have been a therapeutic relationship at this juncture. Later on, as they'd become a ROB pt., then we could "grieve" together, as we'd have established a relationship over time. I know this post is all kind of jumbled, but I thank you for letting me share my thoughts on what was a difficult visit for me. Luckily I amazingly held it together during the visit, but it made me really assess how I need to approach the NOB patients from now on.
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Ruthie,
ReplyDeleteThanks for sharing your experience with us. It is very sad that this happened, but like you said, it does happen quite a bit. I think it is very important to explain to patients the risk of an abortion and I think your preceptor did well by explaining that this was not their fault. My mother had a missed abortion when she was pregnant with twins almost 25 years ago, and it was very devastating for her. When my sister was pregnant last year, I remember my Dad warning her multiple times that she could lose the baby. So obviously, these experiences stick with people for a long time. I agree that it is important to learn people's story before we make incorrect assumptions and then lose that rapport with them. One case I had was a 23 y/o G1P0 who came in for her NOB with the baby's father, but this couple was no longer together. The mom was very excited for the baby but you could tell that the dad was not. When we went to do the pelvic exam, the patient made the dad leave the room. It was very interesting to see this dynamic. The one thing I don't think we did well at this appointment was talk about each person's feelings regarding this pregnancy. I think we could have done a better job of establishing expectations for both the mom and dad.
Wow, I also had a NOB and the FOB come in for a 10-12 week visit with the WHNP, my preceptor. Pt had made it clear to the intake CNA who did the pt's vital signs, Ht/wt, that we "were not to ask about STD's or HPV" in front of the male person who accompanied the pt on this visit.
ReplyDeleteWe went through the whole NOB visit with H&P, ROS, OB-Gyn Hx (including "tap dancing" around the questions about sexually transmitted diseases), and then proceeded with the FHR/uterus sizing assessment.
Well, I and then my preceptor could not get any Fetal Heart Tones with the Doppler. We brought in the Sonagram machine and a physician who operated it and he located the fetus, did measurements and also saw that there was no heartbeat-he said he wanted to look again with a "bigger machine" in another office down the hall. He also said it appeared that the pt had a miscarriage as he scooted right out of the office.
Well, the pt immediately began to cry and then sob with her male partner giving her support. She kept saying it was her fault. My preceptor put her arms around the pt and told her it was not her fault and told her that we don't always know why these things happen. We all were teary eyed for this couple and the baby they would not be having.
Pt and partner were escorted by us to the other exam room where the physician would complete the visit by discussing the fetal demise and options for further treatment and follow-up.
This was a good reminder to me of Dr. Seibert telling us to be careful when first talking to "newly diagnosed" pregnant patients-it is not always a celebratory time for them, some are quite shocked to find out they are pregnant and the news is not so good. AND, you just never know when there may be some problem with the developing baby, and when you may be the Primary Care Provider to identify any abnormalities-there is no black and white book answer on the way to handle these situations.