Help!!! All Labor and Delivery and PostPartum Nurses

  1. I need some feedback from L&D nurses regarding an incident that happened on the Postpartum floor at the facility where I work. A patient was admitted to the PP floor (despite objection) from the emergency room with a retained placenta (over 1 hr). The objection was that technically the patient was in the third stage of labor and should have been admitted to the Labor and Delivery Unit. The patient was unstable while in the emergency room and had delivered a 19-week fetus. In spite of much opposition, the patient came PP, subsequently hemorrhage and was sent to O.R. for a D&C 10 mins after coming to the floor. We just had a meeting with out directors about this issue, pretty much to no avail. They told us that the M.D. who ordered the patient to the floor stated that retained placenta is not considered third stage of labor. All the literature that I have read indicates it is. With this patient having a KNOWN retained placenta and being unstable should she have gone to L&D first, stabilized and then returned to PP? Please help!
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  2. 9 Comments

  3. by   SmilingBluEyes
    should have gone to L and D. slam dunk to me. she WAS in labor still. is she OK???
  4. by   mobyrn
    Yes. She is okay. Thank you so very much for your reply.
  5. by   dawngloves
    Now what kinda sense does that make? If she had a retained placenta after a routine delivery on L&D, would they sent her to PP???
  6. by   webbiedebbie
    Sounds like the hospital where I work PP. We are getting patients admitted who had surgery 1 or more weeks prior and having complicatioins and being admitted to our floor! I had a patient from ER that was s/p hysterectomy one week ago and was admitted with an open incision and infection! This is on a Postpartum/GYN floor. Granted it was an original GYN situation, but once she is discharged, she should not have been allowed to our floor! Especially with an infection! We are also getting sbo's from post GYN surgery with NG tubes.

    Isn't PP supposed to be a "clean" floor?

    We also have to take SAB's on PP. I am not happy with this. I think they need to be in L&D.

    This hospital has always done this and they don't plan to change.

    I also have another rant but will start a new thread for that one!
  7. by   Tiki_Torch
    I agree she should have been sent to L&D for a complete evaluation first. Dawngloves makes an excellent point in her post! I would think that would be one difficult question for the physician and administration to answer to... especially in a court of law... if the patient hadn't had a good outcome.

    Our Mother-Baby Unit received post-partum and some undelivered patients (who were too stable for L&D but not stable enough to go home yet). Once in a while, usually on the night shift, we'd accept a patient who had just returned from surgery for a D&C after miscarriage, stillbirth, or ectopic pregnancy. As soon as a bed was available on the GYN floor, these types of patients would be transferred. When GYN was full we'd sometimes get hysterectomy patients. Over time this changed and if the GYN floor was full, the Admissions department was instructed to call for a Med-Surg floor bed before calling us.

    We had a good nurse manager who really advocated for the patients, and she had a good working relationship with the GYN floor manager. The two of them realized the emotional upheaval a Mom goes through when loosing a pregnancy as well as when a hysterectomy is performed. Not everyone wants to have a hysterectomy... emotionally it means the fact you will never bear another baby slaps you in the face... For example, the realization that, "I'll never be able to give my husband the son he always wanted." and stuff like that can really work on a woman's emotional side. Along with the physical stress, they don't need any more emotional stress added needlessly. The last thing these women need to hear is babies cooing and crying as they are wheeled down the hallway; they don't need to go walking in their halls for post-op and other ambulation reasons and have to pass mothers and their babies... nursery windows... cutsie photos on the walls... pamphlets on baby care... "It'a a boy/girl" balloons... you get the picture. Somehow they were able to work with administration and the Med-Surg manager to work out this plan. The med-surg nurses, who weren't used to D&Cs or hysterectomies freaked at first, but quickly received education from our L&D/Mother-Baby Clinical Nurse Specialist and then there was no problem or complaints from those Med-Surg floors. Another thing they worked out was to have our Sickle Cell Undelivered Moms be cared for on the Cancer floor. I know that sounds strange, but the were usually long term patients with difficult IV sticks, had implanted and other types of venous access catheters, and generally needed much more care in the way of pain medication, nutrition, hydration, etc. and took up loads of our time... they were much more acute care than the normal Mother-Baby patient is.

    Anyway, fortunately our managers understood this element and would work together quickly to get these patients sent to the GYN floor or a Med-Surg floor. As time went on, the Admission department began to realize that they shouldn't even call our Mother-Baby Unit except as a last resort... after calling GYN first and then the Med-Surg floors second for room assignment before calling us.

    Our manager did explain to us, financially, why they couldn't allow a patient to stay in L&D for longer than a couple hours after a D&C, etc. because the rooms were so much more expensive, etc. Sad but true... money is the bottom line.

    I suppose a lot of how a hospital takes care of such issues has to do with the size of the hospital too. Our's was a 600 bed hospital. Many smaller hospitals don't have a GYN floor to care specifically for GYN type medical and surgical patients. I still think Med-Surg should be the second place to look for a bed for these patients. Ones who still have retained placentas need to be in L&D or surgery. Period!

    I'm just glad the woman in this situation received the good care she did on the PP unit there. The fact that she began to hemorrhage 10 minutes after being admitted to your unit screams red flags for administration and risk management. Hopefully they have spoken with the physician quietly and let him know this should not occur in the future. Sometimes physicians are scolded and we nurses never know about it... hospitals like to help physicians save face that way... and since we nurses wouldn't have much work to do without physicians admitting patients, they tend to be treated in a more special way that we nurses are. This is just my humble opinion...

    I'm rambling and I apologize. It's a curse for being able to type fast.
  8. by   mobyrn
    Thank you so much Tiki_Torch for your reply. Please do no apologize for the lengthiness of your response - it really helped me. How wonderful it is for have directors and nurse managers who care enough about patient safety to accomodate them as necessary. Our assistant director is accomodating, but unfortunately she has to have the approval of the director to implement changes. We will be taking this issue to the union.
  9. by   Tiki_Torch
    Thank you for your kind words Moby.:kiss

    I hope your union can be successful in dealing with this type of issue. I shall have faith while I cross my fingers!

  10. by   LuvofNursing
    The floor that a person is admitted to should be the floor where the patient can be stabilized and treated for her condition. Postpartum floors are given standing orders to deal with things like uterine atony, but we cannot stop the bleeding of someone who has a retained placenta, because all the massaging and drugs in the world does not cause a retained placenta to necesarily be expelled. Manual or surgical removal would very possibly be necessary, so you are left caring for 3 other moms and 4 babies (on our unit, at least), while you are spending most of your time with this mom with a retained placenta, crossing your fingers that she expels the remainder of her placenta (as mentioned before is still a stage of labor) and hope she does not continue to bleed. It sounds like some physician education is in order.
  11. by   Fribblet
    If you have the literature to back you up. Show the literature to the DON. If she ignores you, take it to the CNO. If he ignores you, take it up the chain of command on the medical sides of things.

    If you can show it went against evidence, wasn't best practice, and that it put the patient at risk (and by risk, I mean show them the potential for a big lawsuit. They definitely respond to that!) someone will take it seriously.

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