Am I crazy

[Dayray, RN]

This is my patient.

G4 P0 in her late 20's

when i came in at 7 am the report i got was that she had come in at 4 had cytotec placed at 5:30 was 1-2 thick and high.

No contx on the monitor and comfortable. at 7:30 I let her up to walk, put her back on the monitor at 8:30 and had mild contx Q 1- 4 . I was waiting to see what her contx were going to do when the doc came in a few min later and (WTF????) ruptured her at 2cm 30% and ballotable. He left orders to "see what she did and start pit on her at 10:30". She started feeling the contx about 30 min later and I put her in the jacuzzi for an hour. at 10:30 her contx were Q 1- 3 palpating mild but she was hurting allot and she was 2-3 50%, ballotable. my preceptor told me to start pit. The patient wanted to get an epidural because she wouldn't be able to get up to the jacuzzi so we got the epidural and started the pit my preceptor had the CNM put in an FSE and IUPC. for the next 8 hours we went up and down on the pit never going above 10 mu, she would hyperstem, i would turn off the pit and then she would lose her pattern and I would go up again. MV units were 100 - 160. when I left at 7 p she was 6 / 80 / 0 , i gave report that she was 5 cm because I figured that would buy her an hour when they found her to be 6 at the next check (thank you doctor freedmen).

this is my 2nd month at this hospital. coming from a smaller town and hospital I'm not used to all these interventions. I'm not sure but I get the feeling we didn't need to do all this and I have to wonder if I had let her go back to the jacuzzi and walk around a bit or even just used a prostin instead of AROMing her if she would have progressed faster or just the same. the unit was busy and there was a need to make room because the board was filling up but the pit didn't seem to be helping much at all.

I've had training at 2 very different hospitals so I guess I might be confused by the 2 different styles.

I relize the interventions most likely will not lead to a bad outcome in this particular case. I just have to ask though am I crazy? or does this seem like too much and too fast intervention? I'm not anti-induction or anti-intervention I just don't see why this patient had the things done to her she did. My limited experience told me this patient needed more cervical ripening before having Arom and pit (I don't know if that is right thats just what I thought) I left feeling like I had done nothing to help this patient when she thanked me I told her how well she had done knowing I didnt deserve thanks.

insight and advise would be greatly appriciated

[babs_rn]

Was the doc going on vacation?

[L&D_RN_OH]

IMO, sounds like too much, too fast. I think she should have just been left alone for awhile. And I can't believe he ruptured her while babe was ballotable. What an ass. Sounds like he had other things to get done.

[NurseyNursey]

I don't know you well enough to determine your level of mental fitness. I do think that was too many interventions and way too soon.

[kimmicoobug]

We have a doc here who likes to have her patients induced at 0530, usually at week 38 it seems. If they haven't delivered by 5, they are down to C-section. At least this is my observation.

[fourbirds4me]

I see the same scenario quite a bit. However, I think it's pretty dangerous to AROM if the baby was ballotable...

[NICU_Nurse, BSN, RN]

Sorry, NICU girl here- what does it mean if a baby is "ballotable"?

:)

[kmrmom42]

Ballotable means that the baby is "floating" above the pelvis and has not settled down into it. So, when you do an exam you can easily push the head up, it feels like it bounces.

The problem with doing an AROM with a ballotable baby is that of cord prolapse.

Just the other night we had this situation and the patient was not progressing and had mild variables with each contraction. The OB's plan was to "needle" the membranes under a double set up in the OR in the hope that if the fluid just trickled out the fetal head would settle nicely into the pelvis without a cord prolapse occuring.

In fact what happened was the trickle began but then the bag ruptured fully. We were fortunate not to have a prolapse but she still ended up back in the OR an hour and a half later because the decels did not improve and she made no progress.

[SmilingBluEyes]

"ballotable" means the presenting part is "floating"---NOT engaged to the cervix. (generally above 0 station).

it is possible AROMing when ballotable can cause a cord to prolapse before the presenting part. This is why many CNM's/docs do not do this as a rule.

Our docs generally DO NOT AROM when baby is ballotable and when cervices are unfavorable as this case. Seems as too much was being done too rapidly in this case, Dayray, if I understand scenario clearly.