charting vacuum assisted deliveries

[babies_r_us, RN]

Can anyone tell me what their policy is on charting for vacuum assisted deliveries? We are going to computerized charting and there is a place to chart # attempts, amount of suction, time of suction etc. Some feel this is the Dr.'s responsibility to fill this info in and others feel it is the nurses responsibility. Can anyone shed some light on this topic for us? thanks so much!

[babyktchr, BSN, RN]

Any reasonably minded doc SHOULD be writing a vac assist in his notes, in DETAIL. What would be the defense if they didn't....ummmm, I thought the nurse did it? The nurse should be writing notes of her own. We use KIWI vacs now, so the doc is solely responsible for the pressures. You should be documenting number of pulls, pop offs and duration of the pulls.

[NPinWCH]

I ALWAYS document vac deliveries, regardless of what the doc does because everyone of them will dictate it differently. I 'mark' the strip when the cup is applied and pressure is at the yellow/ready mark. Then I make note of the time we start to pull/green pressure, then when it is back down to yellow.

I chart it as:

1200 Vaccum cup applied, pressure to yellow( xmmH2O).

1202 Vac pressure to green (xmmH2O) traction applied during cntx. by Dr X corresponding to maternal bearing down efforts. Fetal descent seen during traction/bearing down. FHR reassuring throughout procedure.

1203 Vac pressure released to ready (xmmH2O) Vac cup remains in place.

I also chart any pop-offs or non reassuring FHRs. The docs have a great habit of dictating like: CMI used during 2 pushes, Vac cup removed as head crowned.

They'll dictate that even when it was for 4 pushes and the cup popped off and the kid had a nasty decel. I've even had docs tell me to change my charting, which I refused to do.

[MemphisOBRNC, BSN, RN]

Ditto babykatchr. I don't document the pressure since I don't know what it was.

[RNLaborNurse4U]

I document:

Kiwi vac applied by Dr so-and-so.

Kiwi vac pop off x (# of pop-offs).

Kiwi vac off by Dr so-and-so.

Of course, I also document maternal pushing, and fetal response. But since I do not know what pressure they are using with the vac, I cannot document that.

We go by the standards on the Kiwi vac package for it's use - max 20 minutes, max 3 pop offs (I believe).

[babies_r_us, RN]

Thanks for all your responses. It sounds like everyone is charting something. Several of my co-workers want to chart "per MD" in all the spaces on computerized charting and I don't think that is enough. We are still responsible to chart how long it is on, how many pop offs, how many attempts, etc. even if we can't see the amount of pressure, right? If anyone can find a standard on this, I would really appreciate it! Thanks again!

[babyktchr, BSN, RN]

I don't use computerized charting, but simply putting in "per MD" SCREAMS it isn't enough. OMG. I couldn't imagine leaving my notes to what a doc wrote in his notes. I don't know about you, but I READ what the doc writes in the chart, and what he considers notes on a delivery/event/repair/etc...and I wouldn't want my name attatched to that at all. It all comes down to thinking about a defense if this would ever become a litigated case. What would you have to stand on with "PER MD NOTES". Protect yourself!!

I wouldn't see any difference in standard/policy on writing a note whether it was written flow sheet or computerized charting. Period.

[NPinWCH]

:yeahthat:

Read the docs notes sometimes...lol, we have a doc that sometimes writes/dictates: as per nurses notes. ANd I can't tell you how many times the doc asks me "How many pulls, how long did we bag that kid, how long did we wait for the shoulders???"

[babyktchr, BSN, RN]

:yeahthat:

Read the docs notes sometimes...lol, we have a doc that sometimes writes/dictates: as per nurses notes. ANd I can't tell you how many times the doc asks me "How many pulls, how long did we bag that kid, how long did we wait for the shoulders???"

:yeahthat: AMEN SISTER