#51 R/O Labor, Liability, and Expecting the Unexpected - Triage Part 2

We are back with episode two of our series of triage. And last episode, we talked about setting up your triage experience, being the first face that they see, how to just start autonomy and help them regulate their nervous system and co-regulate.

In this episode, we are going to talk about ruling out labor, which I feel like should be the only thing we see.

I know it's not possible-

I wish.

... but I'm like, it's so easy.

Yeah.

Are you in labor, or are you not in labor? And so we're going to start with the easiest thing to do, which there are some more gray areas which we'll talk about, and I have questions to ask you, Sarah, but in this episode, let's get into ruling out labor.

So first let's talk about what is labor. We know, and we've talked about before many times, labor is contractions that cause cervical dilation. Easy. Done.

Slash change.

So are they contracting? Yeah, and when she says that she means, are they facing, is baby coming down? So, yes, absolutely. It doesn't feel that simple every so often. And I think that it's really hard to tell patients that, "Yeah, you're contracting and it's really painful, but you're not in labor." And it's really hard to tell, are they in labor, when they're at the desk. There's more that goes into being super simple, but, yeah, let's just talk about the steps we do to rule out labor. Sarah, you want to start, because I know you have more of a more laid out routine than my chaotic brain.

I am a systematic brain person.

Yes.

I think it's important to understand the stages of labor, and so some of this might be repeat, some of this may nail it down or not, but at baseline, I think, us as nurses, we need to be able to speak this language and know exactly what we're talking about.

There are four stages to labor. First, second, third, fourth stage. First stage is when you're contracting and your cervix is changing, and that, we'll split up in a second, until your 10 centimeters. Once you're 10 centimeters, pushing, until the birth of the baby, is second stage, so that's the pushing stage. Third stage of labor is delivery of the placenta, so baby's out, waiting for the placenta, you're in the third stage. And then once the placenta is out, the fourth stage of labor is our postpartum period, or what we can call involution, which is technically the uterus going back to pre pregnant size.

Historically, that's where that six week period came from, but we've expanded since, the postpartum period, into the first year because we know that hormonal changes, the body changes, the recovery from being pregnant and giving birth lasts longer than six weeks. But in general, that's where that six weeks has come from in the past.

And so, when we're talking about rule out labor, we are talking specifically about the first stage of labor. We want to get them through the first stage into the pushing stage. That first stage of labor can be split into three stages of the first stage of labor. That first stage is the latent phase, and that's zero to six centimeters dilation. They're in early labor in that period of time. There's early, early labor and by labor, if I use the word labor, I mean that the cervix is changing.

Early, early.

They're not just one centimeter, that means they're in early labor, no, they're one centimeter, but they were zero or closed two hours before that. Their cervix is changing, and so they are in early labor. So early labor, zero to six centimeters, active labor, six to eight centimeters. Eight to 10 then would be transition. If we're talking about each of those terms, we need to be able to speak to those terms. It would be expected that we know they're in early labor, less than six centimeters.

Now, I will say that when I first started practicing, four centimeters was technically early labor, and that change has happened in my career. I do think it's important to distinguish that labor in the early, early labor phase, like zero to three, zero to four centimeters, does typically look different than the four to six centimeter mark, right? It's still considered early labor, but they're a little more active. They're a little more huffy puffy. They may be begging for an epidural more likely in that stage than they would at one centimeter, as we know.

I think it also is important to identify and understand, that especially when we're ruling out labor, how the patient acts and what their coping level is, is really important, regardless the stage of labor. But, related to chance of a C-section, related to patient experience, and better outcomes, in general, if we are trying to avoid medical interventions and a cesarean, the goal would be, and how we teach childbirth ed, is that they are at home until active labor, which is about six centimeters.

I usually teach four to six centimeters because we know once they hit four or five centimeters, the next check they could be seven, eight, depending on how their labor is progressing. We'll speak textbook, and then we'll speak real life, because there is some nuance with that.

We want them home until six centimeters because they're going to be more comfortable, they're in their own environment, and also, how I like to describe early labor is that early labor is like your body is deciding whether or not it's going to really do the thing. Once it hits active labor, it's decided like, we got this, we're about to give birth, we're moving in the right direction, and that's also where statistically speaking, we would expect, once you hit at the active phase, that labor's taken off. That's where also our failed induction or our arrest of dilation criteria sits, at a six centimeter. Until six centimeters, there's really no timeframe that we need to hold to because it's this period of time where the body's deciding like, is this really it? Or am I going to get it going and then pull away?

I even teach, in my childbirth class, you could be two, three centimeters, contracting, make some cervical change, and still not give birth for a couple more days. It could be a day for you to get to three centimeters. It could be another day for you to get to four centimeters. Again, that is very uncommon and we do want to pay attention to that cervical change, but it's sort of this like, eh, I don't know, let's see. And until labor establishes itself into the active phase, really, you're better off at home because what if it goes away? And that's sort of that risk of needing Pitocin, getting an epidural early, needing augmentation in that way. If we're trying to avoid medical interventions, we meaning that that's their patient's preference, and also knowing that if we can avoid medical interventions, one, it's less work for us, and two, there's side effects to every intervention that we do.

We're, in general, approaching it from a physiology first, letting the body do what it knows how to do, approach. We want to encourage the body to do what it knows how to do because if it can get to six centimeters on its own, it's more likely to not need augmentation or intervention into the future.

If that makes sense, I think that information is really important when we're talking about ruling out labor and where that can play into the education that we give. Because, like you said, Justine, that if we have a patient that comes in and they're one centimeter, contracting every two to three minutes, you walk them, you have them do our labor warmup, you wait two hours and you recheck, and they're exactly the same, then, are they in labor? No, they're not. It may appear as if they're in labor, but from an actual technical standpoint, there is no cervical change happening.

But, we have to understand that that's our medical brain, but from a patient perspective, if I'm contracting every two or three minutes, I want this baby out. It is hopeless for me to hear, "You're not in labor." It feels completely un-validating, of my experience, of my discomfort, and so the approach at a one to three centimeter piece, or an early labor non-cervical change piece, to me, that's first and foremost. Let's talk about that patient population, because they're there, it's not obvious. You check them, they're six, they're admitted, and that's why they're admitted. But anything less than six is that limbo timeframe.

My first tip for that would be, is 100%, you are going to get so much further if you validate their experience of contractions. Even if you're rolling your eyes in your head, even if you're like, "Oh my God, you're so dramatic." Okay, roll it back for yourself, regulate yourself, put yourself in their shoes, and go, "I see you're having contractions. I can't see them on the monitor, but it appears as if you're having contractions. We want to give you all the credit for those contractions. You are working so hard, and I see it, and wow, I do palpate that contraction. Yes. They are happening. Wow, your body is responding to the hormonal changes. Your oxytocin receptors are opening up, which means you're getting closer to birth."

All of those things, first, you're going to need a lot farther with your patient when you then drop the news of, and this is where I would just say, factually, for the patient that's one centimeter and then one centimeter two hours later is, "I see everything you're doing. Everything is good. This is exactly as expected. This is totally normal. But, at this point what we're seeing is that your cervix hasn't changed over those two hours, and in order for us to know that this is labor, we need to see cervical change, and that cervical change isn't happening. It doesn't mean it's not going to happen. It doesn't mean it's not going to happen soon, but what we're seeing right now is, is that these would technically be considered Braxton-Hicks contractions."

I love using the word contraction, it feels very validating to them. You're like, "It's just Braxton Hicks," no, call them contractions because Braxton-Hicks can be extremely uncomfortable for patients. They can be huffing and puffing and moaning and whatever. Now, mind you, as a nurse, I would alert to that and be like, "Hmm, these are pretty strong." And it'll be that type that you send home and two hours later they come back like eight centimeters. You can only do so much, but you do want to kind of pay attention to that.

So, it would be, "You're working so hard, and for sure, labor is coming, for sure, your uterus is getting primed. This likely is early labor." You can say that, they're having regular contractions. "I'm not saying it's early labor, I'm saying it's likely early labor, but your body just needs a little bit more time in order to get you to a place where it's made up its mind that this is going to be the day that you go into labor. And so, our recommendation is to send you home." Our, meaning that your doctor's recommendation is to send you home.

"And the best part about that is that you get to be in the comfort of your own home, or avoiding medical interventions that otherwise might be necessary. If we admit you now, you would be looking at some Pitocin." Likely, if they want an epidural, that's a whole nother conversation we can have, but "We want to admit you when the time is right, because if you're not technically in labor, this would be an induction." And then you have the whole conversation about induction, "And second of all, that, one, you're going to be more comfortable in your home, and also your labor hormones are going to work better. For you to go home, be wherever you want to be. You can be in the shower, you can eat, we're not bugging you, you can sleep, and keep waiting it out until things pick up. Then, that's going to be the best thing for you, and ultimately lead to potentially setting you up for a better outcome."

"But I don't know how to cope." Then you have to give them tools for coping. You have to, have to, have to give them tools for coping. You can't just say-

Okay, but do we have a coping thing coming up, Sarah?

Yeah, we might. First of all, we have a coping class on demand, but let me just tell you, thank you for that plug, that we have just launched, by the time you hear this, it won't be just, but we have launched a one-time only, two-day event, so it's one class over two days, on physiologic coping. So if you've been to physiologic birth, then this is your next step. This is, I'm going to say, most of the content we did in Cancun, but the stuff that we can't do hands-on, we won't be doing, but we'll adapt for online. We're hoping for 1500 people to come to this one class. I do not want to teach it again. You may get little spurts of different things here and there, but this is the course content.

It's entirely new. You get 9.4 CE's from the class. It is not like physiologic birth, it is not like coping. There's a little bit of overlap, but really what it is, is pulling all of it together and saying, "This is how you can help them cope. Here's a million tools, here's what the evidence says, and here's all the different physiological components, how the hormones work, of when we get them coping, when we get their nervous systems regulated, how that affects the physiology of birth, and then therefore, what are our nursing hacks and interventions to help the physiology of birth through different coping techniques."

If you've been to physiologic birth, most of everybody's favorite part is fascia. We will be doing a massive deep dive on fascia, at least two hours on fascia of the class, and I will break it all down for you. We'll give you time to practice. I'll teach you techniques for how to engage the fascia and how that affects labor. It's going to be so fun and exciting. And Krista Dancy will be making an appearance, she will be teaching on trauma-informed care, and on the vagus nerve and that's effect on coping.

It's going to be an incredible two days. It will be recorded, so if you can't make it, still sign up, there's early bird pricing until January 15th. This is quite the commercial, I'm going off, but you get the idea, until January 15th and then the price does bump up, so you're going to want to make a decision fast. And then all of the ticket sales are going towards funding our upcoming app, which is in development. We have taken the leap, it's going to be everything you dreamed, I hope. And again, I say everything, but truly, what you're picturing and what you're hoping for related to bringing together all of the content that we teach, in a practical way, in a really intentional wise way, it's going to do that times a hundred.

Okay? So just bear with it. Trust us. Stay tuned on Instagram. We'll give you updates as we go because we are going to bring you along the way. We've already made the investment, but we need a way to pay for it. And so that's where I was like, what's the creative answer? We can do this class. We are working on 1500 sales, is our goal, to pay for the app.

With that, everybody that purchases a ticket gets their name in a raffle, and we will be drawing people's names throughout for prizes given away for all of those that have purchased a ticket. And then the grand prize will be chosen on the second day of the class, and trust me, we have quite the prize. People are going to freak out. It will be better than anything that we've ever given away. You're going to be privy to something so fun and exciting, and it truly is the best prize we've ever given. Anybody that comes to the class will be entered into that raffle giveaway, which will be announced on the last day, so come to that class and you'll learn all of those techniques to help your patients cope.

Yay. I wanted to do a plug here, for anyone listening, if they're rolling their eyes, like, "None of my doctors will wait till six centimeters to admit. Everyone's admitted it two or three centimeters." And I wanted to share, in case you didn't know, that they're operating based on a labor curve that they probably learned because it was in place for a really long time.

So from 1950 to 2010, right? They had the Friedman's Curve. Friedman was a doctor that studied 500 first time birthers, and noticed that at about four centimeters, everyone kind of took off and went into labor. But things have changed. In 2010, Zhang did a study of 62,000 people, and that showed that it could take a really, really, really long time to get from three to six centimeters, and it shows six to 12 hours to get from three to six centimeters.

I know that as a charge, or even as a nurse on the floor, it's so frustrating, and I'm just going to be honest, when a triage nurse doesn't fight to get a patient sent home at three centimeters. I'm like, "No, she needs to go home." Because what's going to happen? Not only are we slammed, but that's the worst, that doesn't even matter, to be honest. It's like, "No, they're a three, they're going to be three in two hours. They're going to start Pit, they're going to break her water, and then yeah, you're right, it turns into an augmentation." And I say that in quotations, but no, it's an induction, like you said, for lack of better words.

And then, the interventions, and the birth memory, and the birth story, and we hear it all the time. What you said, Sarah, knowing the language is so important. When you're making that phone call, "I definitely think she's in latent labor." And being confident about that is so important. I wanted to ask a question, because I know that one of the questions we got of triage, what they wanted us to talk about was the liability of sending people home when they're two, three centimeters. What if they deliver in their car?

How do we answer that? And how do we help nurses feel more comfortable with sending home that patient that's three centimeters?

Well, you have documentation that they're three centimeters, and we know that that's still early labor, so there's no way to control what happens in the future. Add that to your education. If you're worried about it, what are the exact signs that you need to come back expeditiously? Is that a word? Sounds so smart.

I don't know, but I like it. Yeah.

I know. You need to come back expeditiously. Super fast, and those are your warning signs, headache, blurry vision or changes in your vision, little floaters, you all of a sudden puff up like a balloon. You get super, super swollen everywhere, including your face. Your baby's not moving, we want 10 kicks an hour, and you know what's normal, if it's not normal, then count them. Lay on your side and really count. Look at the timer. If it's been an hour, drink some juice, and within that two hours you're coming on in. And again, it's like one to two hours, it depends on what your protocol is. In general, it's like technically two, but I like to give them the one, because babies should technically be moving.

Vaginal bleeding that's heavier than a period, but mucusy, bloody mucus, at this point, we would expect, we just checked your cervix. Your cervix is super sensitive. It has lots of little capillaries and blood vessels down there, and because we touched it, and because you are likely in early labor, then we expect some bleeding. But if you're all of a sudden bleeding like I chopped off your hand and it's just pouring out of your vagina, or all of a sudden your pain goes from where it is now, and I love this tip for teaching, oh my God, this is such a good one. Hold on, I'll get there. That your pain goes from where it is now to exponentially worse, your contractions are consistently every two to three minutes, your water breaks, and/or you all of a sudden feel the urge to push, head on back in. There is no use, we are not pushing you out of here. We want to care for you if and when it's appropriate.

And so if there's a significant shift in the intensity of contractions and the pressure in your vagina or your rectum, please come back. We'll recheck you. If we have to send you home, we'll send you home. But otherwise, more often than not, you're going to likely be in labor.

So here's my tip that I use all the time, and this is half encouraging and half gives them something tangible to work with, because their biggest fear is that delivery in the car, they're worried about. "How will I know? How will I know if it's time to come back? How will I know that it's active labor? I can't put my fingers up there and know it's six centimeters." Where they are, right then, so I will say to them, and I'll just pretend like you're the patient, Justine.

"So your contractions, think about when you have this next contraction, I want you to pay attention to the sensation. How intense is the contraction? How much pain do you feel? How much pressure on your pelvis, in your vagina, in your rectum, do you feel? How out of control or in control do you feel coping? This is your baseline, right now." Whatever centimeter they are, say they're three centimeters and I'm sending them home, okay?

"Right now, at three centimeters, this is what three centimeters feels like. If your contractions feel like this, any less or a little bit more, you're likely still at the same point. This now becomes your baseline. What you're looking for is double, triple the intensity." And they'll look at me like, "What?" And I'm like, "Yeah, and you can do it." And so what you're going to do, in response to that is, "You're really going to find your breath." You go through the whole [inaudible 00:20:22], all the things we teach in our classes, and you give them actual coping tools. "You move around, listen to your body, what feels right. You want to do that because we want you to use your instincts, prior to your epidural," especially if they plan on one, or not.

"We want you to be able to really get in the flow. By the time you come back, I want you to not be able to hardly carry on a conversation with me. And I will ask my questions, in between your contractions, to get you going, but we want you in the zone unable to focus on anything else going on other than your coping. That is what we're looking for."

"Now, this is your baseline, this does not mean labor. So if you experience this sensation ever again, you go, yes, welcome it over your body. Yes, my body is getting ready, my body is figuring it out. Come on, body, you know what to do, keep it coming, and welcome them over your body, but they're not actually labor contractions." Now you have a new baseline, right? Because other than that, it's like, oh, any contractions is potential for labor, and now you're saying, no, no, no, now these, we can verify, are not actually labor contractions.

That's such a good point. And we see this, and especially nurses at triage, you're like, "Oh, it feels much different than when you came in yesterday." And they're like, "Yes." They know this, and so it's great to give it to them before because we talk about it often afterwards. So, that's great.

Well, I think it's really hard, as much as yes, like, oh, it's so simple, labor is super not simple, and it's super nuanced and it's super flexi-flowy.

Yeah.

And it's like, one person it looks like this, one person it looks like that, and so it's hard to know how to describe that. But I think if you can individualize, and make that connection for them, their cervical exam, how often they're contracting, how well they're coping, what their sensations are, even the number out of 10, if they're cool with that. "Oh, this is a three out of 10," so a three out of 10 now becomes your baseline. We want you at a five out of 10, with a zero being this current state." Or a one, give them some credit.

That kind of concrete data, people want. They need that something to hold onto. And as much as it's elusive, you're never ever ever saying always or never. That just is a great rule of thumb when you're educating in triage and sending people home, or just honestly in life, because then it'll be, "Well, she told me that this will happen." Well, no, this might happen. Make it very loose-

Yeah.

... and open. "It might be this, it might be that, but your body knows best, and what I can tell you right now is, all of this is normal, all of this is good, and the best thing for you is to go home."

Now, I'm having that conversation, I'm not telling them what to do, but I'm saying, "This is what we know by the standard of care, by the expectations, what our clinical data says, that you should go home." I have that conversation, and I get them on board with going home, prior to calling the doctor.

Mm-hmm.

Because then I can say, "She's here, ruled out labor, I checked her, she's three centimeters. She's 360 minus three, still high, intact, baby's category one, contracting every two to six minutes, tolerating them well. Patient is agreeable to going home, and opened, and I've already given education of what it would look like to come back. How does that sound?"

That is different than, "The patient's three centimeters, they're contracting every two to five minutes. They're very, very uncomfortable. They would like to stay." They would like to stay? The doctor's going to go, "Okay, well, how do I be amenable to that?" Versus they want to go home and you're sharing all the reasons why they can go home safely. And that's where the liability piece comes in, you have to know you're ish. I don't totally disagree with people being in triage once they have experience, at least a year, maybe two, before they go to triage because there's so much art and "Mm, I don't know."

And even my instinct, I may look at somebody, even a client currently, but in the hospital as well of, "I don't know, I think we should walk them, there's something else here." Something intuitively, whatever, and sure enough, by the time you recheck them, I recheck them and they're six to seven, and I'm like, "Oh, shoot. Good thing we didn't send them home." There is a lot of that intuition that does come in. But again, we want to work with stats rather than our intuition. Our intuition is just there as an additional piece.

Yeah, and you mentioned walking, and that is something that a lot of units do, right? So the flow of triage, they come out, rule out labor, check their cervix, you monitor baby, monitor contractions, and then, you have to see if they make change.

If your unit is set up to be like you just let them stay in bed and see if they make change, I would argue that that needs to be a practice change to change that.

Change that up. Walking is one of the easy interventions we can do, but we also have a great labor warmup that I know is my favorite intervention to do. You can find that in our store. It's a really nice little badge buddy, and if you've taken physiologic birth or mentorship, you've seen the labor warmup, but what are the little circuits that you put your patients through? That's something to think about, to give them tools. Because, again, you can teach them on the education and then you can teach them like, "Hey, do this when you get home. Take a bath when you get home." The Levonne Circuit, the labor warmup, the Mile Circuit, there's so many things out there that you can do that's not just feeling helpless.

Yes.

Because, I think, you just don't want to feel helpless. You want to do good. It sucks sending someone home, they're in pain, they're crying. You're like, "Oh, I'm sorry. Can you sign this paper of lame education that you're not going to read?"

Yeah.

Well, and this is where, too, I will say, I will plug my YouTube channel as another additional resource to send them to because I have multiple breathing videos, I have a whole breathing demo visualization for coping. I have a How to Engage Your Baby Video, that one's the most popular. I have hundreds of videos on there that are free. Send them there and say, "Practice this," or "Go home and try this."

If you have a recommendation, tell Sarah, because I recommend things and she does them. But [inaudible 00:26:16]. I'm like, I'm getting back to YouTube someday.

Promise, yeah.

No, and you even have it conveniently, for nurses. Playlists, guys, go to these playlists. Don't you have a triage playlist?

I think I do, yeah.

Yeah, because I think I asked. I was like, I've been using it in triage. It's so easy to pull it up, while you're doing that NST, and be like, "Watch this," while you chart and call the doctor. And then they watch it, and they're like, "Oh, I feel good. I feel like I know what I'm doing."

You do that for round ligament pain. You ask for that video and-

All the time. Even as charge, I do it for round ligament pain while they're walking back. "Watch this video. Hand me your phone. Let me look it up."

That's hilarious. I appreciate it.

Yeah.

Okay, so the gray area I mentioned earlier in the episode, I was thinking about, okay, they come in, they're 230 minus 30.

Oh.

Let's say, really thick.

Bye.

You walk them, but they're contracting regularly and they're obviously uncomfortable. You walk them, you check them, they're 280 minus two. It's change. What do we do?

Is that a question for me?

Yeah.

What would I do? Well, reality is, they're still in early labor, and reality is their cervix is changing, but it's not changing that fast. So, I think, there's that.

The other question I would have is, how are they coping? Because there is an element, and we call it a mercy admit. Studies do show that no matter what, if you're actually in labor, getting an epidural at two centimeters versus six centimeters doesn't really matter, and from a coping and psyche perspective, that that might be the answer to help them. We know we have those patients that are one centimeter, one centimeter, one centimeter, and then you get an epidural and they're 10. So, obviously, there's some nursing judgment here, in that realm of things.

But, my question would be, are they coping or are they suffering? And have you given them tools to cope? And do they appear in control, and are they amenable to going home? That patient, still in my head, needs to go home. It could be a day before there's still six centimeters because they're still making cervical change, but that early labor, you got to get from zero to six centimeters over the course of however long. Sometimes it's a few hours, sometimes it's a few days, and we don't know until we know.

And that actually was my sister's labor, so funny. She was having some contractions and they were pretty regular and she was having to breathe through them with her first baby. And again, it's first baby. And her husband were like, he was rubbing her back, and we were watching TV, and I was totally unengaged. I was like, "Oh, good job, la di da." I wasn't doing anything. I was like, I don't even know if this is anything. And so she goes, "At what point do we go to the hospital?"

And I looked at her, and it was my sister, so I was kind of a dick, and I was like, "Oh, I'm sorry, never." "Like what?" "We don't know that this is labor, honey." And she was like, "What do you mean?" And I'm like, "Well, actually, we won't know that this is labor until active labor."

And I was like, that's so weird, it's kind of true, because you could have contractions for a day, and you're like, is it labor? Is it not? I don't know. But when you know is when hit active labor. Then you know that the previous two days were early labor, right?

And so that super strange kind of nuance to labor is a part of your education, that until you hit this criteria I give them, and what I say for criteria is contractions every two to three minutes, lasting at least a minute, and every single one, you are in the zone. You cannot focus on anything else. You cannot say another word. You are uncomfortable, and that's the work that's going to help your cervix go away, to help you meet your baby. And that has been consistent, every contraction is as strong, or stronger, than the previous one for at least... And if it's a prime up, I would say two hours, for a mul tip, I would say two to five minutes for an hour, with the strength of the contractions, all consuming, with the same amount of strength every single time, or more each time, that it doesn't dwindle of like, "Oh, that wasn't so bad," and then the next one you're like, "Oh, my God." So that consistency, regularity, of the strength of contractions is important.

Okay. I don't know if you just realized what you said and if it's a script you have, I've never heard you say it. "That's the work that makes your cervix go away to help you meet your baby."

I don't know if that's [inaudible 00:30:31].

That's great. I just wrote that down.

Great. Use it. Voila.

That's really good. Yeah, that's so true, and so annoying for patients, and I like to validate that too. There's such a difference between, "This is so annoying and I'm so sorry." And "You don't know until you know. And it's so confusing, it totally makes sense you came in, obviously, we've never felt this before."

Yes.

Instead of being like, "Sorry, not in labor, bye."

Mm-hmm.

So frustrating.

Just tell them it's frustrating. Exactly like you said.

Yep. Yeah, exactly. Validating this is totally normal. "I love that you came in, and now, guess what? You have the education. You can go home and just labor, be present, and not worry about delivering your baby, at one centimeter." Sometimes, too, I'll show them how open, on my finger. Think about a baby's head, my head's not going to fit through a hole this big, two centimeters, one centimeter. There's no chance your baby falls out. If you have pictures, I have a cervical exam YouTube video that also might be helpful in that case of like, oh, the baby does not fit. They're like, "Oh, okay. I don't have to be worried about it." So there's that, and then along the lines of this is normal, it's like that validation of "I believe, and I hope, to see you back here." Give them something to look forward to.

And if you are hopeful, if you don't think that they're in labor and you're like, "There's no freaking way, bye. This is silly." Then, "In the next few days, I would expect that you are back here. In the next 24 hours, I would expect to see you back here." I actually might even say that you could be back before I leave at 7:00 AM, and that's okay, but then you're getting them out of there. The goal is that you're not saying come back by 7:00 AM, but the goal being that I am giving you an end game, I'm giving you my perspective.

And that, I think, perspective, is really helpful from a professional sense, for them, when they're just looking for anything to hold onto. "Really? You think I'm close?" "Yes. I think you're close. I think you're so close." And then it also validates that if you go home for 12 hours, that benefits you. And it does. It benefits them. It benefits us. It benefits the labor in the long run, and risk for other things, even if it's two hours. And instead of moving them to a room, their adrenaline spiking because of a new environment, IVs, monitors, all the things, and slowing and stopping their labor. You start some Pitocin, they go home, they feel comfortable because of the information that you've shared. And because they feel empowered into their body, body gets into active labor, they show up six to seven centimeters, get an epidural, deliver three hours later.

It is so validating as a triage nurse, especially how my unit works. So if say I send a patient home at 8:00 PM with all of this stuff, and then I look at the board at 4:00 AM and I see an admit in a room, because obviously they were at the counter and they were puffing and puffing, and I'm like, "Oh, that's a patient." And you're right, and they're like seven centimeters, and then they get an epidural and they deliver, and you're like, "That's great." That's how it should be.

Well, and you did it right. I think that there's even potential stigma of, if someone says, "Well, see, they were in labor." Or you had an argument about sending them home. Sending them home, and then them coming back, a direct admit, to me, is best case scenario.

For sure.

They did it. That's exactly what we want to see. I teach this in my childbirth class, the goal is you show up, it's a quick triage, you're in, less chance of that disrupting your hormones and slowing or stopping labor. No one wants to be triaged 16 times. It might be a good story, but no, that's annoying, and I think you get charged every time too.

And when you say stopping your hormones, right? Yeah, I don't know how that works.

Interrupting your hormones, that's how many more times and how much longer are you separated, probably from your support person too. At least when you're in your labor room, you're with them for sure, hopefully.

You were mentioning all of these tools, and it just reminded me of how important it is for us labor nurses to have responsibility. We talk about the professional responsibility, to have the skills to, one, help patients cope and know what the heck we're talking about. And two, help get baby engaged. Because I think about those early labors, and they're in so much pain, and a lot of times they just need an alignment. They need some ligament softening. They need some heat, warmth, positions to help baby get engaged, and then go home and not be as uncomfortable. And so, if you are listening to this and you're like, "I have no idea how to do that." We can help you. We have multiple resources for that. We have our physiologic coping class, we have our physiologic birth class, we have mentorship. We have so many things that can get you there. You just have to do it.

And we have another massive resource coming.

Yeah, we do.

Early next year-

Help us pay for it.

... that will blow your minds. Yeah. Come to the class. We need help. Yeah, but also the app that's coming will be an additional supplement to all of the classes. Everything works perfectly together, but you're going to really be happy with what we're creating.

Yeah.

No doubt.

I like reading people's guesses. They're going to be very happy.

They're going to be like, "Wait, I'm sorry, what? Our biggest dreams were this, and you 10 Xed it. Like what?"

Super fun. Okay, so yeah, this episode actually didn't go how I thought, but it was good. All labor is so straightforward in a way, but yeah, it's just, yeah-

Well, if they're four and super active, contraction every two to three minutes, palpating moderate to strong, and they can't control their breath, and they're needing so much support, just fine, admit them. Send them home for two hours, fine, but you've got to use your clinical judgment here as well. We're really talking about those early, early labor people, but even a four centimeter, if they're comfortable, and you walk them and nothing changes, they could walk around four centimeters for days, so.

[Inaudible 00:36:13] four.

Keep that in mind.

Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both of you subscribe, rate, leave a raving review and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com, or follow us on Instagram.

Now, it's your turn to go and learn how to educate, triage, and validate your patient's feelings when they're maybe in labor, maybe not in labor, in early labor, and you're sending them home. Let's perfect that script and set them up to either go home or be admitted, regulated, validated, and feeling really empowered by their bodies, no matter where they're at in labor. We'll see you next time.