Pitocin and protocol problems
- 0Dec 2, '08 by PyshRNSo, I'm extremely frustrated about my night last night. I had a 39 wk G1P0 who came in with SROM. She was contracting at this point about every 5-6mins and at 3cms. We admit her. The doctors decide that she should be put on pitocin. Apparently they hadn't looked at her strip while deciding this. So, I bring it to their attention that the baby is flat, no accels, no decels, and absent to minimal variability at best. Our protocol states that in order to start pitocin they must have a reactive strip. She clearly did not. They decided to wait an hour and reassess her. In the mean time, I gave her a little bolus, turned her on her side, and gave her an ice pop thinking that the kiddo might perk up. No go. So I "buzzed" the baby. She perked up for a whole 5-7mins then went back to her flat little self. Finally, I call the doctors let them know the situation had continued to be the same and I didn't start the pitocin. He and his upper level review the strip. They proceed to inform me that the baby can still have a good strip even though it has no accels and wanted me to start the pitocin. I still called the variability absent to minimal, no accels, no decels. In the meantime, they checked her she's 4cm's and they put in an FSE and IUPC. I know the pt is on a "clock" so to speak being ruptured and all, but I just can't bring myself to start pitocin on this lady. At the same time, she's not getting anywhere fast with her body's inadequate effort. Which brings me to my question? Was I right to not start the pitocin? Clearly not the worst strip I've ever seen, but doesn't look good enough for pit to me. Some people at work were telling me as long as I was documenting that they reviewed the strip which was non-reactive and that they told me to start the pit anyway I was covered. In the end, if (god forbid) something were to happen to that baby, I'm the one that pushed the start button on that pump not the doctors. I'm also that one thet is responsible to follow protocol. Correct? What is the point of having a protocol if you don't follow it? :angryfire
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- 0Dec 2, '08 by JolieI support your decision.
If mom is fed, well hydrated, has tried various positions and an attempt has been made to "wake" baby up without success, I have to think that the child simply has little to no reserve with which to tolerate a pitocin-augmented labor.
I don't know how forceful your medical staff is about starting pit, but they always have the option of doing so themselves and remaining at the patient's bedside to monitor her throughout.
Please let us know the outcome, if you are able to do so.
- 1Dec 2, '08 by magz53I too had a horrible pit night last night. My G 2 pt. being induced because of hx of macrosomia and this baby was in my estimate 10 lbs or greater. I come on and she is 5 cm. and contracting q 1 and a half to 2 minutes, palpating strong and lasting 70-80 seconds on 16 mu of pit. Sorry, I am NOT "upping" it as the MEDwife said to do. I told her if she wanted it increased to do it herself. She said she couldn't !! Variablility wasn't great and she was making progress. Fast forward a half an hour and now we have a prolonged decel and the pit is off. She ultimately delivered a fish-eyed 10 lb. plus baby who needed rescusitation. Blood gases weren't bad tho and I am wondering if it was because of Mom's O2. I am sooooooooooooooooooooooooooooooooooooooooooo sick of all of this. I am sick of being barked orders to by everyone and sick of no one listening to someone with 20 plus years of experience. I have certainly seen c-sections done for lesser reasons than this baby's distress. The midwife did put an IUPC in and the MVUs were 210-260. She was happy with that but obviously the baby wasn't. Trust me when I say I am counting the days til I can retire.
- 1Dec 2, '08 by PyshRNThanks for the reassurance. I'm somewhat new at L&D nursing (7 mos on the floor). It does seem like we 'pit to distress' a lot. They always want the pit upped. Well sorry if she's contracting every 2-3 and making change in her cervix then why? At least I know I can go home feeling like I was being an advocate for my patient and her baby.
I get so frustrated with these residents lately. I used to work in critical care where when you called a resident, they would listen to your suggestions and at least consider them. Where I'm at now it seems as if you suggest something you might at well not waste your breath, or even worse expect the total opposite!
- 2Dec 2, '08 by bagladyrn GuideI would not have started the pitocin on that patient either. I've actually had docs at my current contract say "Let's go ahead and start the pitocin so we can see the baby's response and then go ahead with the c/section"! (They seem to love to cut here).
Your coworkers are skating on very thin ice if they think that notifying the doctor will absolve them from responsibility for a bad outcome! As you said, you are ultimately responsible for your actions and for following the hospital protocols and standards of care.
If you reach an impasse in a situation like this, your best recourse is to start up the ladder by notifying your charge nurse, supervisor, etc. If the provider is adamant it can even be appropriate to request a change of assignment if another nurse is willing to follow the doctor's directive. I actually did this once with a situation where the doctor was insisting on restarting pitocin on twins when the "b" twin deceled as soon as the contractions reached a moderate strength (and I had 2 other active labors besides). This doctor literally stamped her feet - she was that annoyed at me. The house super backed me up and my coworkers told her they were unwilling to take over the patient as they would do the same as I did. Ultimately, the patient waited (strip was okay with no contractions) until the other two were delivered and then had a c/section.
- 2Dec 2, '08 by mom2michaelI just left a facility that I swear the motto on the front door was Pit to commit, Pit to the max and Pit to distress. All the doctors knew was Pit and turn it up, turn it up, turn it up. All the time, turn it up. I kid you not, that was their answer to everything. It didn't matter what I called them for - the only question they ever had for me was "What is her Pit on" and their only response was "Turn up the Pit". I feel your pain
And no, I wouldn't have started the Pit either. Baby can't handle what they've got right now. No need to add a HUGE amount of stress on poor little ol' baby.
- 1Dec 2, '08 by JaneyWYou did exactly the right thing, Pysh. I'm sorry your coworkers gave you flak. More than the fact that they were wrong about their liability in that situation, why did they not have more concern with the health of the baby? I too often hear "strips" and "pit" and "status" discussed with no real feel for the actual patients involved. We are advocates for our patients. We should not be engaging in practice that will be harmful to them.
Have you joined AWHONN yet? Do it now and do your best to attend the convention next June in San Diego (worth visiting anyway!). You will find hundreds of like-minded OB nurses and your practice and concern will be validated. Going last year really helped boost my confidence in my practice and gave me many more evidence-based arguments for safe practice.
On the same note, I have spent the last three months away from L&D nursing (I work registry) as I was student teahcing in basic med/surg. I am finishing up my MSN so I can teach--hopefully in OB. There doesn't seem to be as much contention between the nurses and the docs on the med/surg floor. I had been getting very anti MD and am glad to have backed away for a bit. I will be back in my home base during winter break. Hopefully I will not have these kinds of situations, but I think that isn't realistic. What do you all do about these feelings?
- 0Dec 4, '08 by PyshRNThanks for all of your responses. I found out when I went back in to work the last time that the pt ended up with a vaginal delivery anyway. I didn't get to speak to her delivery nurse to find out how it went.
Janey W, I have not joined yet, but I was hoping to soon. Maybe someone (my hubby) will suprise me with a subscription?!?
- 3Dec 4, '08 by SmilingBluEyesI have come up against some angry doctors who either thought I should start pit or up the rate when it was clearly not only inappropriate, but dangerous. I stood my ground politely, except in one case where the dr became unprofessional. I simply responded, "I am uncomfortable doing this and will not. If you choose to manage this augmentation, that is your call. I will not start pitocin on a baby with a questionable strip, esp. on a woman who is dilating at a rate of 1 to 2 cm an hour WITHOUT IT". She got huffy and went to the dr lounge (did I mention the woman was a TOLAC???) and went to sleep, never saying another word to me.
The next time I saw the dr, I woke her at 0600 to come deliver a newborn who turned out healthy and fine, spontaneously without one breath of pit. She was truly amazed this lady "could do it without pit". I just told her I hate to say I told you so.......but....
Stand your ground. Your patients depend on it.