Dear Friends:
 
When Florence Nightingale took a cadre of the first trained nurses to the 
Crimea, she would not let one nurse lift one finger to help one wounded solidier 
until the commanding officer at the scene gave permission. This is the model 
of nursing practice that I was educated in, and that is still in operation 
today.
 
Following orders is at the heart of nursing. One can not practice 
independently as a nurse, unless one has a specialty degree (anesthesia, midwifery) and 
even then, physician back-up in some form is mandated.
 
When I worked in labor and delivery at a teaching facility, physicians 
attempted to have me fired, citing an incident where I refused to administer IV 
pitocin to a multiparous woman having minute-long contractions every 2-3 minutes. 
I was ordered to hang pitocin IV. I asked did he want her uterus to fall out? 
I refused. When pressed, I invited the resident to hang the drug himself. 
 
When I was being queried in the nursing director's office about this 
incident, I was told that doctors had to do things "for practice" so when they got out 
into the real world, they would know how to take care of people. Never mind 
that I had a license of my own to protect; I was expected to do what I was told.
 
As a nursing student, I did practice on patients, doing many things for the 
first time.. I gave my first injection to a sleeping veteran. (I was sweating 
and he was so sweet to keep sleeping!) However, the medication I administered 
was essential to his recovery. The injection was not some arbitrary activity 
for me to practice to give medications intramuscularly so when I had to do it 
"for real" someday, I would be proficient.
 
However, in the hospital, I saw residents practice on patients. One example 
lives in my heart forever;  I worked with a woman that was having a precipitous 
labor; she came in to the hospital at 6 centimeters dilitation and delivered 
less than an hour later. Still, the resident managed to use the vacuum to pull 
the baby out after cutting an episiotomy; I will always remember that "man" 
tell this mother who was still lying flat on her back, in stirrups, that "this 
baby really tore you up." That was a bald-faced lie; HE is the one that tore 
her up. However, he needed practice with the vacuum.
 
Following orders is complicated. Of course, we need the folks with the most 
skills and training to lead the team. I wouldn't have a debate with a 
neurosurgeon about care of my friend with a brain tumor.
 
Yet look what happens when one profession has been given all the 
power...........now 1 woman in 3 in the US has her baby cut out of her; induction has 
become the norm, epiduralized labors are the standard. It is amazing that 
breastfeeding is still hanging in there.
 
Never mind that postsurgical complications increase the chances that a woman 
will be rehospitalized within a month of her scheduled cesarean section. Never 
mind that 25% of all prematurity is the result of medical intervention (March 
of Dimes 2005). We've got to follow those orders, now don't we?
 
Professional breastfeeding management has had to learn to fit into the 
system; it is a challenge because many of us are better read and informed about the 
evidence than the physicians we work with. (All due respect to the ABM and 
those physicians that are doing great work; however, we can all agree that those 
are still the minority. And probably have their own battles to fight!) We are 
promoting a practice that is not truly supported by the medical system as a 
whole. 
 
(Witness the debate about formula-discharge packs as an example of how 
entrenched industry is in our system. I know people that are IBCLC that want to give 
these bags out, despite buckets of evidence and common sense. If 
breastfeeding was truly endorsed, discharge packs would not be a topic to discuss; they 
would have gone the way of the dinosaur.)
 
 
Following orders is a complex issue. I see a huge need for dialogue and 
collaboration.  In the States, the whole healthcare system is so fragmented and 
isolated. The most extreme example of that I have heard of recently is of a 
hospital where the maternity ward was just renovated, one group of pracititioners 
is making enquiries about becoming Baby-Friendly, and another group in that 
same hospital is seriously considering closing the maternity ward, because 
maternity services are "non-productive".
All 3 things going on at once in the same facility, 3 separate groups all 
going different ways. Talk about the right hand not knowing what the left hand is 
doing! I wonder how this situation will resolve.
 
If we all were involved in on-going communication, true dialogue, and 
collaboration, most of the challenges we deal with now would vanish. Communication is 
a key to any good relationship, whether personal or professional. Good 
communication, to me, is 180 degrees opposite to following orders.
 
My goodness, can you all believe that I just got up? I wonder what sort of 
day this will be.
 
Thank you all for giving me a chance to vent.
warmly,
 
 
 
Nikki Lee RN, MS, Mother of 2, IBCLC, CCE, CIMI

www.breastfeedingalwaysbest.com



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