As an RN who works one half of my shifts on nights, I see the exact
behaviours on our OBS floor as have recently been described.

We Have vague 'policies' in place. We all agree that we need mom's
permission to supplement, and ask for permission when it is believed to be
'medically necessary'. Therein lies the rub. The only documentation that
seems to be recorded is "at mom's request".

We have very vague unwritten, guidelines of 'medically necessary', and
ultimately there is a great deal of individual assessment by the nurses and
disagreement re whether an infant falls into the parameters that
necessitate supplementation. Certainly, if blood sugar levels were to be
used as criteria, it might inhibit willy nilly supplementation for such
reasons as: "because mom is so tired and she says she wants to sleep " or
"the baby was so dry that it needs some extra fluids" for which mom is
easily persuaded that this is the right thing for her to do.

However, our community hospital does not routinely do blood sugars unless,
again, it would appear to be medically necessary (i.e., newborn >4060 gms,
<2500 gms, symptomatic etc). Is it unrealistic to expect that for every
baby that is supplemented, some form of rationale beyond "at mom's request"
be written. We are making inroads to realistic expectations re voiding and
stooling in the first few days, so there isn't quite the panic there used
to be if the babe hasn't peed for 12 hrs but some continue to believe that
the baby should be voiding copious amounts and if not, supp, supp, supp, to
force the ssue. "See, she hadn't peed for ages, she was so dry. I fed her,
she peed, and now everything is better!!!".

I think that if the individual institutions required the nurses to write
down on the official record their reasons for wanting to supplement a baby,
there would be less of a tendency to do it, out of a probably genuine
belief that they are doing a tired mom a favour by letting her skip a feed,
by telling her "it's OK, the baby is nursing well, it won't hurt to miss a
feed, and you need to get some sleep. And, the baby is a little dry. So, is
it OK if we give the baby a little formula?". If a hospital requires
evidence based practice, and discouraged tradition based practice, the
tendency to supp may decrease.

I fight an uphill battle daily (nightly) with some of my co-workers who get
very angry if I suggest that I intend to take a baby out to nurse on demand
through the night (we also have very few moms who choose to have 24 hr RI,
in fact, very few moms offered the choice along with information re the
benefits of 24 hr RI). They will follow behind and somehow report back to
me that the mother has changed her mind and wants the baby fed in. We still
have a problem with lack of consistent information. Although I feel
undermined, I will not exacerbate the issue by then undermining the other
nurse (not good for my patient either).

I find myself relenting, backing down, for the sake of peaceful working
conditions, but try to continue to teach by example every chance I get
(i.e., trying to take advantage of opportunuities to speak to moms in the
ear shot of other staff) and I understand that change takes an incredible
amount of time and patience.  Many nurses only see that they have done
these things for so many years and sincerely believe that "it never hurt
anyone".

Hoping this will improve,

Bobbie (frustrated in Grimsby)

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Bobbie Middlemiss RN, BScN, IBCLC
e-mail: [log in to unmask]

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