# OB clinical



## GoodMomma (Aug 6, 2006)

So last night was my 1st night in OB (I'm a nursing student). Anyway....I HATE it, for the obvious reasons. It's only 6 more weeks luckily and I hope it goes by fast! Anyway, there's 7 of us then our instructor and before doing a tour of the floor we were in the conference room talking about what we'll be doing this rotation and I'm just dreading the circ topic of course. At one time she talked about how a lot of African women have been circ'ed and it's a real problem over there....she says she has seen some women that you can't even tell they were circ'ed but then others she wonders how they got pregnant. She said it's barbaric, etc etc. So then later on she's talking about us having to do discharge teaching to a new mom, for example a mom has 2 girls at home and now has a boy with a "newly circ'ed peewee". 1st off...I can't stand pet names for body parts so hearing a NURSE say "peewee" instead of penis was like nails on a chalkboard and then to totally go off on how barbaric female circ'ing is but talk about male circ'ing as no biggie....just annoyed the crap out of me! How am I going to survive? Then we finally go to the nursery and see babies with their "lovely" bottles in their beds...blah! The particular baby we were learning an assessment on was breastfeeding but still had bottles in her bed. So the instructor says in this case put the bottles in the drawer under the baby because it'll be tempting for the mom to give up nursing....ok great advice, but why even give a breastfeeding mom formula anyway? Walked quickly by the "procedure room" and seen the torture board. OMG!!! 6 more weeks! Oh and we have to do a paper on ethics regarding maternity....and can you guess what I'll be doing mine on??? YUP....CIRCUMCISION! We have to present our papers to our classmates and clinical instructor...LOL...can't wait for that. I'm normally not so outspoken off the computer about this but I'm so sick of this! Anyway.....vent over!


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## Mrsboyko (Nov 13, 2007)

That is going to be tough I am sure. My Midwife worked in maternity in a hospital for a whole 2 months beofre getting to the point of revulsion and leaving. Please just keep in the back of your mind that these women are very vounerable. I know I would probably try to convince every mom there that circc was completely unnecessary and all that (becasue it is true!) but these women have been thru so much already. Questioning is fine, barrating is not. Not saying you would, but just keep the compassion meter for the women really high, that is all. You will get thru this and come out stronger for it.


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## glongley (Jun 30, 2004)

I can really empathize with you. I work in a newborn nursery and am around circumcision every day I go to work. It is hard.

However, I would encourage you to keep an open mind about learning from the experience, but do take every chance you can get to educate your fellow students and clinical instructors about circumcision and the normal intact penis.

As far as educating parents, it is hard to make a dent in the postpartum period, because for most parents it is already a fait accompli in their minds, and they don't want to hear anything about why it's not a good idea. However, as long as the foreskin is still attached to the baby, there is still time to educate. Some famillies in particular may still be conflicted about it, and your words may be the only ones they hear to feel supported in making a decision to not circumcise.

I have tried a lot of different ways to open the conversation about not circumcising. I think rather than taking an approach that opposes what they already think they want to do, asking them more neutral questions like "Have you considered not circumcising?" may be better received without producing defensiveness. Maybe they never thought not circumcising was an option, maybe they have various fears about not circumcising that can be easily answered. Part of the nurses role is to assure informed consent, by assesing patient (parent) understanding. Find out what research they have done, ask what they know about how a circumcision is done, what the possible complications are, what the foreskin is and what it's there for. At the very least, if they haven't done any research (most likely), tell them that this is not an inconsequential decision because it's a normal, healthy body part, and once it's gone you can't put it back, and to please do some research before they make any final decisions. I specifically suggest they Google "circumcision video" and "foreskin function." I also think you have to train yourself to ASK QUESTIONS, LISTEN, and DRAW OUT, rather than launch into lecture mode. Sure there is information that you need to transmit to them, but they need to feel acknowledged into their feelings and concerns, and they need to engage with the topic rather than just have you bombard them with facts.

If any other nurses here have worked up a way of talking to postpartum parents about this, PLEASE CHIME IN!

Good luck with the clinical, and please keep us posted.

Gillian RN


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## GoodMomma (Aug 6, 2006)

Thanks to the both of you for your advice. I know I have to remember that most of these parents probably don't know there's the option of leaving their baby intact. I shouldn't assume that all know there's no medical need but are still going to circ. It's just so hard.....but I must get through this. The thing that bugs me is it seems like we're only taught how to teach the parents circ'ed care. Nothing in our paperwork says anything about intact care. This is only clinical and the subject hasn't been brought up yet in lecture class so I'm wondering what will be taught. There was a little boy in the nursery last night and I felt so bad for him knowing he's probably getting mutilated today.







This is such a crappy rotation!


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## proudmomof4 (Aug 29, 2006)

This must be so hard to see!
You've heard great suggestions already, so I'll just add that you can offer information but you have to let go then. Just as a LLL Leader or an IBCLC can't "make" a mother breastfeed you have to leave the decision to the parents. Even if on this forum there's probably a wide consensus that it's NOT a parent's decision whether to circumsize or not - from a nurse's point of view it is.


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## Smokering (Sep 5, 2007)

Eugh, I can't imagine. How horrible.







On the one hand it's great that you're in a position to potentially save dozens of boys, but on the other, you're only one voice and your position makes all-out activism tricky to say the least. Here's wishing you an immense fund of tact, courage and the ability to dissociate yourself from the situation when necessary.


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## Ron_Low (May 11, 2007)

Just remember you don't have to tolerate unethical amputations on non-consenting individuals. If you see an amputative surgery in progress where there is no diagnosis of defect or pathology and no chart on less invasive solutions tried, report it to the police immediately. This applies to any body part you might witness being amputated, from any patient of any age.


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## BugMacGee (Aug 18, 2006)

I always tell the parents what to expect with a circ. Eg. you have to watch for bleeding, be sure to keep the poop away from the open wound, babies often scream when they pee, often they don't eat well after the procedure, watch for signs of infection...

Very often, their eyes bug out like "What???"

This has worked exactly _twice_ to convince families not to do it. Any suggestions for more effective tactics are welcome


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## Belle (Feb 6, 2005)

Quote:


Originally Posted by *BugMacGee* 
I always tell the parents what to expect with a circ. Eg. you have to watch for bleeding, be sure to keep the poop away from the open wound, babies often scream when they pee, often they don't eat well after the procedure, watch for signs of infection...

Very often, their eyes bug out like "What???"

This has worked exactly _twice_ to convince families not to do it. Any suggestions for more effective tactics are welcome









I doulaed for a couple that did not circ their son. They said that the lady who lead the hospital tour made circ sound so barbaric and gruesome that none of the couples on the tour wanted to do it to their sons. I wish I knew exactly what she said.


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## JenBuckyfan (Nov 30, 2007)

Due to the number of circs still occuring in the US, I do think its important that you have exposure to it in clinicals (I would also have major difficulties having to be around it...). However, ultimately it is the parent's decision, right or wrong. My CNM, who told me her DH was teased as a child for being intact was totally pro-circ when their son was born. However, they still didn't have the procedure done on him. She told me that if parents choose, she will do the procedure - she believes that if it is going to be done, the infant should have it done in the most respectable way and with the least amount of pain possible. Maybe you can help try to make sure that if it's done, that the infant is cared for in the best way possible and that the parents know everything they need to know to care for their circ'd son. I'd also make sure that they know what the procedure involves - if you are able to show them pictures on how the process works at the hospital you're working at, that would be helpful. I think many parents don't want to know and don't honestly know exactly how the procedure is done. You'd think with all the research people do in regards to cribs and carseats that they'd look into this too, but most don't think twice and probably have no idea what's involved.

I also agree with the fact that so many people don't know that they don't have to circ their son and many have it done because it's what they know and it's what their parents had done and since most men don't have any issues with their circ'd penis there seems to be no reason not to do it. I think letting couples know that not circ'ing is an option, that it's not medically necessary, and offer to be a resource for info on how to care for an intact penis and that you're available to answer any questions they may have. If you are allowed, maybe you could have a brochure that highlights the pros/cons that are on both sides of the issue and point out that circ is cosmetic and it can always be done later if their son chooses. Sometimes even just putting the bug in someone's ear will make them think twice about their decision. If you are unable to prevent circ on one baby, maybe the bug you placed in their ear will resonate and a future baby will be untouched.

You mentioned that caring for an intact penis hasn't been discussed - I would bring this up and ask when it will be covered. After all, there are parts of the country where you could work where circ is not as common. I'd make sure to have the info on why you don't retract, etc with just in case whomever is teaching doesn't know what they should...


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## glongley (Jun 30, 2004)

Agree that getting good info out to parents and colleagues about intact care is important, and probably less threatening of a topic than trying to fight circumcision directly (not that that shouldn't also be a goal). When I've asked nursing students what they are taught about care of the foreskin in nursing school, usually they are told that parents should pull it back and clean under it - that's it! YIKES! So it is important that nurses and parents be informed about foreskin development, which supports correct care instructions, which is: leave it alone, just wash off the outside, never forcibly retract, and teach the boy the three Rs when he's older.

My hospital gave out no information on care of the intact penis. Strange because we give out info on care of the circumcised penis, and care of girls genitals. I talked to our unit director about it, and got her approval to have the NOCIRC #4 Care of the Intact Penis pamphlet placed in ALL parent packets (to assure that all parents of intact boys had access to it, in case nurses would forget to go an get them and hand them out individually, which I'm sure they would certainly do!). And I also developed and presented a 20-30 min inservice for all the OB/mother-baby/nursery nurses on our unit, on care of the intact penis, which allowed me to inform them about foreskin anatomy and function to some degree, though I focused more on development. This part of the role of the nurse - to see things in patient care that need to be improved, and then take action within one's organization to improve them.

Gillian


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## billikengirl (Sep 12, 2008)

If you end up doing your paper on circumcision, do let us know how the presentation turns out!


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## feminist~mama (Mar 6, 2002)

Quote:


Originally Posted by *GoodMomma* 
I HOPE a parent asks me rather then a maternity nurse that most likely is pro-circ.

Why would a maternity nurse likely be pro-circ???


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## kate3 (May 4, 2007)

I was thinking the same thing. Why do you think a maternity nurse would be pro circ? I've been a nurse for 20 years, have always done OB, have taught OB nursing, and I am not pro circ. Neither are any of my colleagues. Be careful not to prejudge.

As a clinical instructor I have some unasked for advice








I think it is great that you are considering doing a paper on a topic you are passionate about. Just make sure that everything you state in the paper is referenced with solid facts. I have read a lot of clinical papers in my life and when students are very attached to a topic the paper can turn into a bit of a rant (which is a very quick way to get points taken off). Unless the paper is a position statement or opinion piece, stick to the facts and back them up with what is known from the medical, nursing, and research literature.
Good luck in school.


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## JBaxter (May 1, 2005)

My last OB nurse was definately NOT pro circ. Infact was going down my list ( no vax no vit K etc) I said we arent going to be circing she replied OH good I hate when parents make that choice. The 2nd day my nurse came in and re asked...She stated she was required to ask each day shift and if I was there the next moring I would be asked again and to please not be offended it was just the morning protocol. ( this was the same nurse that said she would be back in with my rogam shot







Im O+ so I freaked on her a bit)
One of my OBs is VERY anti circ and will gently tell parents it is very unnecessary to cut baby boys.


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## fruitful womb (Nov 20, 2004)

I've read this stated several times in this thread that "This is a parent's decision"

okay

if its really the parents decision, why not wait for them to ask about the procedure?

As the default, instruct the parents on intact care. That'll bring up the circ topic; if its on their mind.

This way, there is no need to shift the blame.


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## Contented73 (May 14, 2006)

Quote:


Originally Posted by *kate3* 
I was thinking the same thing. Why do you think a maternity nurse would be pro circ? I've been a nurse for 20 years, have always done OB, have taught OB nursing, and I am not pro circ. Neither are any of my colleagues. Be careful not to prejudge.


I don't know, if everyone is so anti-circ, why aren't more health care professionals refusing to perform or assist with circs? It amazes me when I hear all these nurses or midwives and even OBs whispering behind the scenes how awful they think it is, yet they march right in and help the babies get circed anyway.

If docs started to refuse to do them, and nurses started to refuse to assist with them, I think it would make a drastic impact in the number of circs being performed. It's like there's this elephant in the corner that no one will address, and everyone hides under the "well it's really just the parents choice" argument. Drives me nuts.


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## KGB (Jan 30, 2010)

Quote:


Originally Posted by *Contented73* 
I don't know, if everyone is so anti-circ, why aren't more health care professionals refusing to perform or assist with circs?

$$$$$$$$$$$$$$$$

Could also be pressure from hospital/clinic administrators or managers that are only interested in the bottom line.


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## chelle.ra (Jul 28, 2009)

Quote:


Originally Posted by *Contented73* 
I don't know, if everyone is so anti-circ, why aren't more health care professionals refusing to perform or assist with circs? It amazes me when I hear all these nurses or midwives and even OBs whispering behind the scenes how awful they think it is, yet they march right in and help the babies get circed anyway.

If docs started to refuse to do them, and nurses started to refuse to assist with them, I think it would make a drastic impact in the number of circs being performed. It's like there's this elephant in the corner that no one will address, and everyone hides under the "well it's really just the parents choice" argument. Drives me nuts.

i would argue the real issue is that there is not enough unbiased education about one's choices when having a baby in the hospital - the status quo is expected, one might get a pamphlet on the "'other: option(s). it's not really a matter of "choice" if one is not give options with supporting FACTS.

having medical professional REFUSE to do procedures that people have the RIGHT to do is not an option i would like to see. keep your personal opinions at home, and educate yourself and your patients with the best information available, and soon enough people will make the "right" choice.


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## Roxswood (Jun 29, 2006)

I would absolutely expect to see medical professionals refuse to do procedures that people have NO RIGHT to do. Circumcision of a penis that is not attached to your own body, or in clear medical need comes very firmly under that.
There is very little chance you would ever find a doctor to agree to circumcise a baby in the UK without significant medical reason or religious reason in which case you would have to hunt around and pay privately. You couldn't get that covered under any private health insurance.


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## mum2row (May 11, 2007)

Quote:


Originally Posted by *Contented73* 
I don't know, if everyone is so anti-circ, why aren't more health care professionals refusing to perform or assist with circs? It amazes me when I hear all these nurses or midwives and even OBs whispering behind the scenes how awful they think it is, yet they march right in and help the babies get circed anyway.

They are not refusing for one big reason. It is not their decision to make. It is the patient (parent's) decision to make. It is important for the healthcare professional to ensure that the parents are informed so they can make the decision that is appropriate for themselves.
Until circ is no longer acceptable (which education can help change) health professionals have to respect their client's choices.
OP, like has already been mentioned it is important as a nurse to remember that people need to and are capable of making their own decisions. It is your responsibility to provide information and respect THEIR decision.


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## Quirky (Jun 18, 2002)

I totally disagree that it is the parent's decision to make and that healthcare professionals should therefore perform circumcisions without regard to their own opinions. I believe it is a total breach of medical ethics that doctors continue to perform circumcisions in the absence of a demonstrated medical need for THIS baby to have THIS surgery.

There is no single other body part that doctors amputate on parental demand without any medical indication whatsoever.

I mean, I suffered through recurrent bouts of tonsillitis my entire childhood until I finally had my tonsils removed in college. Not a single infection since then.

Should my history of repeated, painful infections give me the right to demand that my children's tonsils be removed at a very young age, despite the fact that they've not yet had a single infection? Or what about the fact that I prefer the way my throat looks without those nasty, swollen, pitted, disgusting tonsils sticking out, clearly visible if I laughed really big?

After all, it's very easy to live a long and healthy life without tonsils. Heck, it's not that long ago that routine tonsillectomy was completely normal and accepted no matter whether kids had had problems or not.

There's no law against routine, unnecessary tonsillectomies. They didn't stop because parents got educated and said, no, enough already, I'm not getting my healthy child's tonsils out.

They stopped because doctors finally refused to stop doing them because the surgery was completely unnecessary and did more harm than good.

So if no doctor in his or her right mind will perform a tonsillectomy on my children without demonstrated cause, why shouldn't a doctor be able to say to parents -- no, this is not medically necessary and I refuse to do it?

The baby is the patient, and the baby's interests must come first in any body-altering surgery. Parental choice is simply irrelevant, because parents shouldn't have the right to have ANY surgery performed on their babies unless that surgery is medically necessary. That is what the issue of proxy consent is all about.


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## mama24-7 (Aug 11, 2004)

Quote:


Originally Posted by *mum2row* 
They are not refusing for one big reason. It is not their decision to make. It is the patient (parent's) decision to make. It is important for the healthcare professional to ensure that the parents are informed so they can make the decision that is appropriate for themselves.
Until circ is no longer acceptable (which education can help change) health professionals have to respect their client's choices.
OP, like has already been mentioned it is important as a nurse to remember that people need to and are capable of making their own decisions. It is your responsibility to provide information and respect THEIR decision.

but the child is the "client," not the parents. circ is no more a parental decision then what career the child pursues when they're an adult. yet another myth perpetuated by some health care "professionals."

sus


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## dannomac (Aug 16, 2009)

mum2row, it is interesting that you say that it's the parents' decision. I see that you're in Canada. Did you know the the College of Physicians and Surgeons of Saskatchewan has come out and said that circumcision is a legal grey area, and the Saskatoon Health Region doesn't do neonatal circumcisions anymore? Progress is being made.


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## becca_howell (Jan 3, 2009)

GL, and I look forward to reading your paper!


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## calngavinsmom (Feb 19, 2003)

Quote:


Originally Posted by *chelle.ra* 
i would argue the real issue is that there is not enough unbiased education about one's choices when having a baby in the hospital - the status quo is expected, one might get a pamphlet on the "'other: option(s). it's not really a matter of "choice" if one is not give options with supporting FACTS.

having medical professional REFUSE to do procedures that people have the RIGHT to do is not an option i would like to see. keep your personal opinions at home, and educate yourself and your patients with the best information available, and soon enough people will make the "right" choice.

You might not like to see it, but the option to refuse is already in place. Doctors have a right to refuse to any procedure they find to be unethical. In fact three of our provinces medical authorities are actively encouraging doctors to refuse to circumcise baby boys on the grounds of circumcision being unethical and inappropriate. Check it out.

http://www.circumstitions.com/Sask.html

It is even found in the CPS position statement that many Peds will no longer preform circumcisions.

http://www.caringforkids.cps.ca/preg...rcumcision.htm

And on a personal note, I live in Ontario and when my second son was born, the ped on call asked if we were looking to circumcise and when we declined, she stated "Good. I refuse to do them and you would have to find yourself another physician."

I think it's great that these docs are finding their moral compass and sticking up for their real patients, the baby boys rather than just trying to keep their parents happy.

take care,


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## jenP (Aug 22, 2002)

Quote:


Originally Posted by *chelle.ra* 
having medical professional REFUSE to do procedures that people have the RIGHT to do is not an option i would like to see.

But according to medical ethics, parents do NOT have a right to have a healthy baby boy circumcised.
In order for a parent to have the right to choose this procedure, there would have to be clear pathology present, for which more conservative measures had been tried without success, leaving surgery the only option for treatment. Also, the condition would need to be urgent enough that the surgery would need to be done soon (i.e. it could not be put off until the boy was old enough to make informed consent himself therefore his parents would have to make the choice for him now.)

These are the medical ethics under which doctors and hospitals supposedly operate. They have been ignoring their own stated ethics for years in permitting circumcision of newborns for "cultural" or "cosmetic" reasons. Just because doctors have been performing this procedure in direct opposition to medical ethics for years, does NOT translate into parents ACTUALLY having a right to have this done to their sons. They have no more right to cut bits off a healthy boy than off a healthy girl. Try asking your doctor to do a little labioplasty on your baby girl. They will refuse, because it is against medical ethics. You have the right to have labioplasty on yourself, and even if you are very happy with your surgery and love the way it looks and want your daughter to look like you, you won't find a doctor willing to do it. Would you argue that they should leave their personal opinions at home, give you information, and then, if you as the parent still wish the procedure done on your baby daughter, you think the doctor should just DO IT ANYWAY??

No, absent any pathology that requires treatment, parents do NOT have a "right" to have permanent amputative surgery done on their children.

Jen


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## Eeyore35 (Aug 2, 2009)

Quote:


Originally Posted by *mama24-7* 
but the child is the "client," not the parents. circ is no more a parental decision then what career the child pursues when they're an adult. yet another myth perpetuated by some health care "professionals."

sus

I'm not arguing on whether it SHOULD be the parents' decision, but, yeah, as it stand now, it IS.

I don't have a probem with dr.'s refusing to do it. I found out during prenatal classes that no dr.'s in my town will do it. They weren't sure how far I'd have to travel to get it done. And we'd have to pay for it,not covered by our provincial health plan. My doctor never brought it up. I had a girl, but I didn't find out ahead of time, and I was surprised my doctor never asked. I wasn't planning to get it done, so I never brought it up.


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## Smokering (Sep 5, 2007)

Quote:

having medical professional REFUSE to do procedures that people have the RIGHT to do is not an option i would like to see.
And having medical professionals FORCED to perform procedures they find morally abhorrent, whether or not it is the patient's right or his parent's, isn't an option I'd like to see either. Yikes.


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