Antepartum dillema

  1. I had a situation last night at work that I am hoping for some feedback on... I am an agency nurse on contract with antepartum unit at a non-profit teaching hospital. Basic rundown of situation...

    Only nurse on the unit, had a tech and secretary, with 5 patients, 3 on continuous EFM. Including 1 cervidil induction. Had a 29 weeker PTL on cont EFM. Right at change of shift this PTL pt had a decel for 3 min to 100's from 150's. This went unnoticed by me since there is no "central monitoring", only one computer in nurses station. No monitoring capabilities in other patient rooms. By the time I came back to station I noticed this decel that had been back to baseline for approx 3 min. To room, pt on back...teaching blah blah blah... report to resident. About 1 hour later another decel this time deeper and longer with need for interventions. Report to resident. 3rd time, about one hour later, need for more interventions...called to desk for assistance from tech with o2 tubing ( I only have two hands, so trying to turn pt, hold/locate fht's audible in 70's, get bolus... unable to do everything) the tech literally called the room on the pt phone asking what she (pt) needed. I was like " I NEED SOME HELP" Decel going on over 5 min now. So, after report to resident I called L&D charge which is also our charge RN and told her she either needed to take this pt down to L&D(2nd floor, APU is 4th floor) or send me a nurse. 2 hours later I got a nurse...YIIPPEE!!! While l&D charge Rn on floor pt had significant decel x10 min. I happened to be at bedside at start. My problem was that I had this pt and 4 others, I felt that for this patients best interest she needed to be down in L&D for closer obs where there were more people to assist with decels. Charge Rn was in the position that since they weren't going to do anything different (POC) that she should stay up there. Attending finally came to evaluate and they said to the pt that she would be transferred to L&D because I didn't feel comfortable with her up there. So to me it seemed as if they made it seem like I was not comfortable enough with my skills to watch her. Despite the fact that my only concern was that I would be in another pt room during a decel and have no idea.

    So, any feedback on how this situation could have been handled better on anyone's part. To me, this is just not safe patient care. More worried about one of the L&D nurses having to take a patient than what is in what I feel pt's best interest. By the way, L&D had 7 nurses and 3 patients...HHHMMMM....Me, 1 nurse and 5 patients. (the nurse I was sent was told by charge RN that she wouldn't have to take any patients and she didn't)L&D is my specialty so this is not a slam on L&D nurses at all.

    Sorry so long but this is very frustrating. I guess I just needed to vent to people that understand the situation.
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  2. 10 Comments

  3. by   VivaLasViejas
    I'm a med/surg nurse who frequently floats to LDRP, and what you've described is nothing short of unsafe staffing, especially in such a high-risk area of the hospital. Where I work, labors are usually 1:1 and EFMs 1:2 at worst, and our staffing isn't all that wonderful.....If I'd been in your situation, I would have refused the assignment and asked the supervisor for an unsafe-staffing form to fill out at the beginning of the shift; this way you can CYA and let the powers that be know that this is unacceptable. If only one more thing had gone wrong for the pt. having decels and you ended up with a bad baby, it could have been disastrous for all concerned, including you and your license!

    You may want to reconsider contracting with that hospital, if this is the way they care for their perinatal pts. I've worked in this area enough to know that lawsuits are common, even when care is done right and babies turn out bad despite the staff's and the doctor's best efforts. The place is a catastrophe waiting to happen. Get out while you still can!
  4. by   SmilingBluEyes
    Can we spell D A N G E R O U S???

    WHY OH WHY if staffed this way, is there NO central monitoring? HOW FOOLISH this IS!!!!


    I would refuse, as the poster before me said. NO if's and's or but's.......

    OB is litigious enough w/o making it worse with such grossly unsafe staffing. I feel sorry for you; sorrier still for those patients for whom this hospital obviously has NO regard. I would be outa there---after a letter explaining explicitly WHY I had to go.
    Last edit by SmilingBluEyes on Aug 15, '03
  5. by   SmilingBluEyes
    One more thought;

    antepartum does NOT necessarily equate LOW acuity as you now see. The manager/administration need to be aware of how dangerous the situation REALLY IS...

    An occurence/incident report IS in order. It will not only make them aware (as if they are not already), but make them know YOU are aware and covering your you-know-what.
    Last edit by SmilingBluEyes on Aug 15, '03
  6. by   imenid37
    management's strategy is to make you feel like a failure when they create unsafe staffing conditions. this stategy often allows some "snotty" nurses to use you as an object of their anger and ridicule. plain and simple--you were totally right-TOTALLY!!! this was a bad situation and for the sake of your pt. and your license she needed to be in l/d. if some nasty nurse had an extra pt., then it was up to the charge rn to shuffle the assignment or call the manager/supervisor for an approriate solution.

    i used to work on mother-baby and antepartum and had a very similar situation to this w/ a 24 weeker who i got moved to l/d w/ pih and blurry vision. multiple calls to dr. and finally she was moved to l/d (because i was too nervous and inadequate to care for her and my other 6 pt's). well the l/d nurse recieving her (well-known as a really snotty diva) rolled her eyes at me as the pt. was moved to her bed and told me, in front of pt., "this is about the last thing i need tonight. " well, the pt. had a few labs and was evaluated by her physician FINALLY after 6 phone calls from me and the nurse on the previous shift. seems she had a detached retina and was stat sectioned and her little baby sent to a large tertiary facility. ms. nasty wouldn't look me in the eye for weeks. you do what you gotta do. better to irritate some nasty co-worker or physician than have to tell it to God or someone's lawyer. you're a good nurse and you shouldn't let them make you feel anything less.
  7. by   Texagain
    On my APU, we would not have taken the assignment. While we do take 5 patients, we would not have taken 5 with three on continuous. Three continuous is the max in that particular situation. We also don't do cervidils on the unit. They require too much monitoring with a patient load of 3-5.

    In your situation, our charge would have backed us up and sent the pt to L&D. My unit has about 30 beds. I think we would have sent one to L&D as opposed to calling in another nurse as our staffing is generally 4:1.
  8. by   HandsOnTLC
    Hi, Amber -

    Boy, you are working in Hell, aren't you?

    For one thing, antepartum patients need specially trained OB nurses to care for them just as L&D patients do. It's a specialty, just like ER, CC, ICU, etc.

    Another thing - this facility is hardly practicing within ACOG or AWHONN guidelines, which mjlrn97 addressed in her reply. One big factor in lawsuits.

    Third - what on earth are you doing cervidil inductions for in antepartum? What trimester?

    This hospital is very much at risk for suits along the lines of gross negligence. I would suggest that you certainly file an incident report, keep a copy for yourself (altho' we're always told not to do that, do it anyway). And get out of there as soon as you can.

    In my 21 yrs. as an RN, 17+ in L&D, I have learned that hospital administrations don't usually give a rat's patooty about the individual RN's. When it comes down to their losing some bucks, then they might take action.

    I wish you good luck and MUCH BETTER surroundings in your next position!
  9. by   AmberL&D/RN
    Thanks to everyone who replied to my posting. After being on contract at this hopsital for almost one year I have decided to not renew. I know to most of you that sounds like a no brainer but it is a big desicion for me due to financial reasons.

    In answer to a few of the questions posted, This particular hospital has no set policy on how many continuous monitoring patients any one particular nurse can have at one time. This makes it particularly hard because you don't have a policy to fall back on, it just sounds like you are whining.

    We also do most cervidil inductions on this floor (term patients). L&D does not believe these patients "deserve" a bed in L&D until they are "active". Regardless of G's and P's. I can't count how many times I have taken a patient down at 7+cm or even complete because they were "too busy" to take them. These patients often times become 1:1 before you are "ready".

    We also deliver IUFD's on this floor which I feel is inhumane because they can't even get an epidural. So not only are these patients going through the worst emotional pain, they have to feel every bit of the physical pain. These patients aren't considered any more critical than any other patient so having a patient with this going on doesn't lower your ratio. They do use cytotec with these inductions. I guess they think that because it is an IUFD it doesn't have the potential of the same risks as when using it on term inductions.

    Just a note to the original post... that 29 weeker delivered literally in the bed the next day. She never had an SVE because they "didn't want to stir the pot". She even PROMmed and I guess nobody thought... HHMMM what's going on here?

    Anyway...I am just doing my time now. I will continue to be a patient advocate and do what I feel is in the patients best interest.

    Thanks for all the advice and support. I was starting to feel like I maybe I was in the wrong but ya'll brought me back to reality and I thank you.
    Amber
    Last edit by AmberL&D/RN on Aug 25, '03
  10. by   HazeK
    suggest you document the unsafe staffing in legal letters to nursing administration...so, if you every are stuck going to court, you can show THEIR negligence by inadequately staffing the unit!
  11. by   OBNurseShelley
    YOU'VE GOT TO BE KIDDING ME???? What a crock, ANYONE that has taken care of a pt with an IUFD, knows full well the acuity of that patient can change INSTANTLY, Who the hell is making the decision that IUFD's aren't high acuity, ever had one bleed out?? OR go into DIC?? HOw about the emotional and grief needs of the patient?? NO EPIDURAL??? THAT IS INHUMANE, and if I were the pt, I'd sue for not managing my pain, I don't care if you're having a live baby or a dead baby, if you want pain relief YOU SHOULD GET IT, REGARDLESS of what the "unit" believes. I am appalled and can't believe a unit is run this way. Ever had a pt on cervidil have a 10 minute d-cel and need a crash section, sounds to me like they're ASKING FOR A LAWSUIT! Good for you for getting the heck out, could be the best decision you've ever made! Good luck!
  12. by   SmilingBluEyes
    Boy oh boy oh boy. Do what haze says cause it's likely these guys are gonna be involved in a HUGE neglicence/malpractice litigation at some point and YOU may become ensnared in the fray! This place is HELL for nurses but even WORSE for patients, I sure as hell would not want my family or myself to have anything to do with it, ever. Houston, hmmm? I wonder what hellhole this is....

    (I know you can't say here, just musing)

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