Published Oct 15, 2003
Well, last night we had a delivery by an RN, she has a little over a year of experience handed it off to the senior RN when she got there. The baby came out and was fine, no nuchal cord good apgars....So my question is, when it is up to the RN to do the delivery AND you do have a nuchal cord, I know as much to reduce it, but if is not reducable...do you clamp and cut, and pray for no shoulder dystocia...what to do????
I haven't had the experience yet but have been close on a number of occasions, I *think* I could handle it but last night got me thinking as what to do in that situation.
I guess what I was really trying to ask in this post was IF you were stuck in a situation and you had to do that type of delivery and the outcome was poor, what would be the legal ramifications???
I've never been in that situation and being that I am still not as experienced as most nurse on my unit, I would try to get someone else to take over for me. However, if I had to do it and there was a tight nucal I would clamp and cut.
What else could you do? you cant leave the baby on the perineum or you ARE going to have CP. In situations like this you have to do the best you can to provide the best possible chances for a good outcome with less then optimal resources.
If you did have a dystocia and ended up with a bad outcome you would probably be named in a suite BUT if you failed to act you would defiantly be sued, successfully and imo justly.
You have to look at it like this.
1# you don't cut the cord, baby sits on the perineum until doc arrives and without a doubt will be brain damaged and possibly dead.
2# you clamp and cut and very likely have a good outcome, or if you do end up with a dystocia you can honestly say that your intervention was appropriate even though the outcome was bad.
personally it would would haunt me to know that I did nothing and had a bad outcome because I failed to do what I knew needed to be done just because I was afraid to preform an intervention that is technical out of my scope.
If I did clamp and cut but still had a bad outcome, I would at least know I did the best I could.
Clamping and cutting is the only option that provides the possibility of a good outcome. For a lawsuit to be successful there has to be harm caused so if the outcome is good your all clear on that.
....But even with a good outcome you can still be nailed by the state board for practicing out of your scope.
Back when I worked ICU something smiler happened.
One night we had a recently extabated patient on the floor who became apnic we badged him but his airway was swelling. He had to be intubated we all knew it but Anestassia was in a 6 hour case and there was absolutely no way this man would have lived without intubation. One of the our nurses was also a flight nurse. She intubated people all the time on the helicopter so she tubed him. the man lived and came back later to thank her.
The nurse was turned in to the state board by another ICU nurse. No one knows why the other nurse turned her in but she did. The flight nurse had her license suspended, was fired from both her jobs and has a record on file with the BON. even though the outcome was good and the man's family testified for her, the intervention was out of her scope.
Lol don't you love being an RN? no matter what you do, you are legally at risk. Still the only way you are going to save that baby is to clamp and cut.
anytime an RN delivers a baby there are STRONG legal ramifications, best believe that.
I have a great L and D pocket reference that addresses cases of dystocia, various maneuvers and potential outcomes. Maybe you should get it, too
http://www.inmypocketbooks.com It's called Labor and Delivery in My Pocket. GREAT book.
Also Hope you have good malpractice insurance......
I have never been the situation you mentioned; guess I would handle it as it came and at least get an DR from ER up to help out if no other is around......anesthesia too. Just what I would do.
I had this happen to me in one of the 3 precip deliveries I have had to do as an RN in L&D.
G2P0 - a labor eval (cervix unchanged in the 2 hrs that she had been there so far), who I had go into the jacuzzi to help with her contractions. Was 3cm going into the tub....I was watching her very closely (6th sense, thank you!). 10 minutes after I get her in the tub, I go out to the nursing station to get a quick sip of water and hear THAT SCREAM. You know that scream.... the *pushing scream*. I run back to the jacuzzi, check her in the jacuzzi, she's complete with a very bulgy bag. Out of the tub back to the bed we go. I tell the tech to grab me a delivery cart, get it set up stat. I tell the other RN to call the doc STAT, that she's complete.
I have my tech in the room, have my NICU nurse with me as well...bulging bag out of vagina, you can see the mec floating in the water (ugh....just my luck). I tell the tech to get anesthesia up STAT for mec delivery. I'm all gloved up and ready, trying to get this girl to pant. She's pushing involuntarily. Then we have SROM of mec stained fluid, pea soup-like, so it's not too bad. Get suction set up, and here comes the head. Tight nuchal x1. I absolutely cannot reduce it. So I clamped and cut it. What else could I do? Couldn't let the kid sit there on the perineum. NICU nurse helped me suction baby on the perineum (ok, it was NOT the most sterile delivery, but she had gloves on too), and we encourage mom to push, push push. Out comes baby, no dystocia (thank GOD!). I hand off quickly to NICU nurse, who suctions baby out some more. Baby breathing spontaneously, good apgars (8/9 I think). Anesthesia arrives finally, no mec below cords (do I hear an Amen?). Baby to NICU for short term observation, and is brought back to mom soon after. Baby was absolutely fine. A beautiful 6 lb girl.
Ahem...doc arrives in time to deliver placenta. LOL I laughingly tell her that I want to split her delivery fee with her.
I was sweating bullets delivering this baby, especially after I clamped and cut the cord. I knew that this baby had to be delivered quickly at that point, and starting praying in my mind that all would go well. I'm not normally a person who prays either! I would clamp and cut if I am ever faced with this situation again.
Thanks for the replies. I know that I would clamp and cut, but just when you think of it, it is a scarry prospect. I get nervous when a OB does it and prey for no shoulders and a very fast delivery...but I can't help but think that in these situations that us nurses could get really blasted for something like this in the court of law. Even though we have no choice, the kid only has 7 minutes on the perinuim before irreversible brain damage and or death, I just can't think of a more scarry predicament. We are fortunate for in house OB but even that night, they were not fast enough to respond and when he did get their he just watched us finish the delivery and said "good job" As for the shoulders, well we were all required to go though the shoulder dystocia drill which we were instructed on how to handle that type of delivery from both perspectives, so that was good, I have that under my belt. Just sad to think that in this legitious system and country that you have to worry about doing the right thing, becuase even with following protocols, you can still get named in a suit...even when you were doing every thing you possibly could in a given situation. As for calling ER or Anesthsia docs...well thats a joke at least in our hospital, they wouldn't know what to do and have proven that, they see pregnant ladies and run when it comes to delivery. Sometimes I see these situations and wonder where the nursing profession is going, we do everything in our power and somehow it all comes down to us and docs always have their excusses...the bottom line is the patient. Can you tell it has been a rough week???? Only 6 more nights to go...
Thanks for the info on that little book. It looks great and I ordered one!
you are welcome...
it is TINY and when you get it you will wonder why it cost 19.95...but it is PACKED with good "stuff"
hope you like it. let me know!!!!!!!!!!!!!!
Thaught it would be interesting to share that the other night after writing this, that it happened to me...neo was in attendance and the house OB was delivering another patient, attending OB was en route! Everything turned out fine but just kinda ironic!
A friend of mine who has done OB for years said something that made me laugh and I guess holds very true...don't mention things that haven't happened ie "Gee, we haven't had a bad dystocia lately..." or it WILL happen, just so fate can prove it does!
Anyhow...have a good day!
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