C-sections! When to call em?!

[seemerun]

Before I started in Labor and Delivery I pictured myself being the nurse who was an advocate for natural labors and not rushing to c/s.

But reality is...different. Maybe my view is tainted by my work experience. I love where I work but it is a large tertiary care center with the highest level NICU. So we get all the high risk patients. Anyway, my tolerance for sitting on sketchy looking strips is becoming quite low. There seems to be a theme - I notice it more with a particular provider but I know he's not the only one. There is all this pressure to reduce the c/s rate. So basically he won't section unless it is a category 3 tracing and this is crazy to me. With a lot of patients you can see the writing on the wall pretty early. I can understand wanting to give mom the benefit of the doubt, but waiting UNTIL it's an true emergency seems so risky. I am tired of seeing babies born with APGARS of 2/4 and having to go on cooling protocol. :-( Whats your comfort level?

[klone, MSN, RN]

Depends on the situation. I remember sitting on a strip for an ENTIRE SHIFT (they had opened the OR at around 1800 anticipating during dayshift that we would need to section her, and I came on at 1900, and she delivered at 0645). She was a midwife patient, and both the midwife and I wanted to call it, but the chief resident came in to consult a few times and reassured me. Even though we were having VERY low variables with UCs, between contractions the baby would recover and even have a bit of variability. So she continuously reassured me throughout the night that, at least at that moment, the baby was okay. Finally, at 0600, even she was ready to throw in the towel, but then the parents wouldn't consent to a C/S, and she ended up having an SVD at 0645. That was seriously one of the worst shifts I've ever had (the FOC was also verbally abusive to staff and we had to call security twice).

Anyway, not sure what you can do other than let the provider know your concerns, document that you did so, and realize ultimately it's not your decision. Maybe advocate for a STAN monitor?

[seemerun]

I don't know what a STAN monitor is? Sorry,still relatively new to this specialty. :-) There always what ifs. I mean we have crashed a patient before and then had 9/9 APGARS, but obviously that's a whole lot better than "what if" we had done this section 2 hours ago urgently but emergently, instead of going round and round with the unpredictable labor and having a poor outcome.

[klone, MSN, RN]

A STAN monitor stands for "ST Segment ANalysis" it's an FSE that actually does fetal cardiography and can better detect acidosis. Research has found that it decreases C/S because even if the strip looks ******, the monitor can tell if the baby is truly acidotic.

The Stan Method « Neoventa Medical

[queenanneslace, ADN, MSN, APRN, CNM]

There are situations where it's apparent that a c-section is absolutely necessary - cord prolapse, severe bradycardia - and I think you just yank cords and wheel the bed down the hall. But there are many situations in labor that require a judgement call - and making that call is above my pay-grade as a nurse.

I've been thinking more about how physicians will get an SBAR report on a dicey, iffy looking strip (variable decels, mod variability) and they'll order Pitocin. OK - and we just turned OFF the pitocin, because those are our protocols. Anyway - I'm starting to see it from the physician's perspective (maybe ??) if we add Pit, and the kid's heart tones go south, then there is no judgement call to make - you know, the baby "declares himself."

That's how you get out of making that tough call. I'm not a physician, and it's not a call I want to make. We'll do stat sections and get babies with great apgars - which is GREAT. But it reveals just how imperfect fetal heart rate monitoring is. EFM has a pretty dismal false positive rate. So we'll be doing crash sections when it's not really a crash situation - that's the nature of the business. But you never want to err in the other direction.

Above my pay grade. It takes a team to get a baby out in a hurry. When the doc makes the call, I'll be a part of that team that makes it happen. If it's a judgement call - on a maybe, iffy, dicey, icky category IIs that don't resolve.... egh - not my decision.

My job is to make the doc aware, and to get them to assess the patient and the strip and to make a decision.

I think it's a very tough call to make.

There's always the chain of communication when we're not getting the response we want. Have you ever considered that? Are you in situations where you're concerned enough to try that avenue?

[rbytsdy]

I've been thinking more about how physicians will get an SBAR report on a dicey, iffy looking strip (variable decels, mod variability) and they'll order Pitocin. OK - and we just turned OFF the pitocin, because those are our protocols. Anyway - I'm starting to see it from the physician's perspective (maybe ??) if we add Pit, and the kid's heart tones go south, then there is no judgement call to make - you know, the baby "declares himself."

Yep - pit to distress. But then the physician is a hero in mom's eyes for saving her baby.