Policies on starting pit on nonviable fetus

[tryingtomakeit, RN]

I'm curious what your policies are in your various facilities regarding pitting women who are in active labor, but the fetus isn't viable - or when it is questionable whether the fetus is viable.

Our policy states that we start pitocin only when the absence of fetal heart tones is verified by ultrasound (per MD).

I had an MD the other night scream at me when I wouldn't start pitocin on a woman who had been told in his office only the day before that she was nearly 21 weeks. She came in 3 cm, 0 station, 100 percent effaced - bleeding. She said when she had been seen in his office the day before, that he had given her antibiotics for an infection the day before for a "uterine infection" (this had been her first MD visit).

When I notified the MD, he came in, did an ultrasound, and confirmed that she wasn't abrupting, but he said that her membranes were ruptured. He ordered pitocin because the fetus wasn't viable (he said 18 weeks), she was in active labor and would deliver anyway (there were no contractions palpated or on the monitor at the time). We had no prenatals on the woman, so he left to go get them in his office.

I wasn't sure what to do since she was only 18 weeks, so I called my manager at home. She told me that we DO NOT PIT unless there were no FHT's.

When he came back, I told him that this was our policy and that I couldn't start pit. He started yelling at me, "FINE! We will watch her die then from hemorrage or from sepsis!" I just watched him scream, throw his fit, and order some labs. Just before he left he said that there was a way he could get around the policy. He said he could consult with another Dr., call in clergy, and if all were in agreement that the mother was in danger, that we could start pit, but that the patient wasn't really in danger, so he wouldn't so that at this point. This was all said calmly, then he turned to me and told me to call him when his patient was dying.

When I read his orders, I was astounded to find that there were no antibiotics ordered, so I gave him time to get home and I called him. When I asked if he had meant to order them, he said, "What for? She isn't running a temp." I reminded that she had said she received some from him the day before for an infection, but never got them filled. He just said, "No!" and slammed that phone down.

The same Dr has been repremanded time after time for ordering us to start pit on these women, and each time the situation ends the same way.

I was just curious if any of you have faced similar situations and how it was handled.

[twinner]

I work in a Catholic hospital, so no induction unless there are no FHT or unless the mother is infected. The other hospital I work at (not Catholic-owned), anything goes.

[nursejohio, ASN, RN]

We do inductions for iufds, anomolies that are incompatible with life, and severe pih. The policy we have is that if we can still get heart tones and the baby isn't viable we (nurses) do nothing to stimulate ctx. Either the private doc has to come in and do it, or get one of the residents to manage the cytotec, pit or whatever they're using. If the baby is 24 weeks or above, NICU does a consult with mom, the nurse can manage the induction and we deliver in the OR same as we do with any preemie. If there is no heartbeat, we can also manage the induction. Our unit manager has drilled that into our heads, we do nothing for non viable babies.... it's our license on the line if we do

[SmilingBluEyes]

You are BOUND to follow policy. You did the right thing to notify your manager, but go the step further to ensure she actually does something here. I have been yelled at by dr's also, for only following policy when they disagreed. I stuck to my guns. Your patient's wellbeing and license are on the line. You can't make exceptions to policy willy-nilly here.

Don'tlet them cow you into doing anything wrong or against your policies. These are the first ones who will HANG YOU OUT TO DRY if you do....just to get themselves off the hook. And there will be nothing risk mgt or legal department can do to help you then

Funny one of his concerns was "sepsis" yet he never wrote for abx....things that make you go "hmmm".

Anyhow in cases like this, never be afraid to invoke chain of command and notify your house super of the situation as it's occuring!