Feeling worried...

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Specializes in L&D.

Hi everyone, this is my first post here. I'm a nursing student and will graduate in December. I work right now as an intern in a small LDRP unit (about 40 births/month). I'll try to make this as short as possible, please bear with me...

Today I was helping one of the RNs at a delivery. The patient (a G2P1) had just started to push and was having a hard time composing herself (no epidural, erratic pushing efforts, kept crying she couldn't do it). The RN and I were giving her instructions on how to push, but she primarily was pushing spontaneously and not listening to us. I counted for 10 anyway during pushes, along with giving her lots of encouragement.

Fast forward ten minutes--perineum's starting to bulge, head is low and the RN called the Dr. in. I had heard the nurse mutter something about the patient being "narrow" and probably needing an episiotomy. Dr. walks in and starts to gown up. The patient's still pushing, and I'm still encouraging her (my mistake). Looking back, I seriously doubt she would have been able to stop even if I were telling her to, the baby was coming fast. The head is about to pop out, the Dr's still gowning (he's only been there about 2 min. tops) I call out "head's coming" and he rushes his hands to control the expulsion. It pops out and the baby's born seconds later (7 lb 10 oz). I take care of the baby, everything's good on that end.

She had a 1st degree periurethral and 1st degree midline laceration with repair. Ok, not so bad. I'm out of the room about 30 min. later and the RN and I run into each other. She said she wanted to talk to me about how the final stage was managed...I knew what was coming. She said I was encouraging the patient to push and therefore the Dr had no time to prepare to do an epi. I agree that it was a mistake. Honestly, everything was happening so fast that I didn't realize (in my limited experience) that the birth was so imminent. She said she was torn up pretty badly (although there was no swelling, little pain, etc).

So we're back in the pt. room and the RN is assessing lochia and fundus. The fundus is firm but there is heavy flow, esp. when massaged. This continues for an hour or so. She's got pit running in her IV but we later discover that it's infiltrated. New IV is started and by this time the Dr.'s ordered a hemabate. The RN is telling me that she and the unit manager think that the bleeding may have been caused by a cervical tear from the head's "rapid descent." When I hear this, I feel like she is blaming this problem all on me. I am seriously worried that I made a huge mistake and I'm so worried there could be a bad outcome to this. At shift report, 2.5 hours after the birth, the bleeding was still moderate to heavy, despite a firm fundus. Her hgb was 9.8 and her hct was 30%. There was no baseline to compare this to (labs were drawn after the birth and heavy bleeding).

I guess I'm feeling like this is all my fault. I'm going to call tomorrow to see how she's doing. I feel so foolish about what happened in the delivery room. Does anyone have any input? I keep having this fear at the back of my mind that they won't be able to stop the bleeding, a hysterectomy will be done and they'll say it's all my fault b/c I was "encouraging" her. I know, I'm paranoid..... :madface:

Thanks for reading if you've gotten this far....

Nikki

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Hey Kirs,

Let me first just say,...I have no exp. in L& D other than my own internship during nursing school. ( 7mo's ago). IMHO, don't beat yourself up over it. It sounds like it was madness in there, which can lead even the most veteran nurses to make mistakes. You admitted, you coached when you shouldn't have, and that shows taking responsability; and, now it kind of sounds like some just want to point fingers. As you describe, whether you enc. her or not would not have made the difference. If this was truly a precepitis birth, you telling her to stop; wouldn't have changed that baby coming. During my internship, I was picking up a 37 wk. G1P1 mom from the ER who had SPROM at home, while in the elevator...she stated and I quote...."I think, I'm pushing. I paniced and told her not to, and closed her legs...yes, closed her legs. As I was wheeling her on the unit, she began breathing heavy and saying something doesn't feel right. I told her to deep breath, we were almost there. I grabbed a nurse and headed to the traige area. Little did I know as I removed her sheet from her legs to place it on the bed......she was crowning! Later the nurse needless to say, chewed me up one side and down the other....I admitted, all my fault...just a poor judgement call. The right thing to do was get her back to the ER on a stretcher and have staff eval her and move only if safe and with staff. My primary RN told me a precip. birth can not be stopped! She then went on to ask me..."You're not thinking about working in Maternity when you graduate....right?" So don't worry, things happen...its not like you turned on her pit...hahah...I know its not funny, but I truly believe things just happen, we are not perfect. Good luck.

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Specializes in Emergency.

I do not think that you were at fault for anything. It is normal for a womans hgb/hct to drop after birth. You pushed for a normal vag delivery, which is what the woman wanted. I delivered my son at home, so i may not be of much help here. haha

I would have much rather bled more and be sutured than to have an episitomy. This is not my nursing opinion, but rather my womanly opinion.

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Let me start off by saying that I'm not a nurse yet, however, I have been a doula for the last 8 years and have been present at ~200 births.

If the doc was gowning up in the room, the nurse (or someone) had to be in there with you. My question is, why didn't this nurse just tell you, "Tell her not to push, but pant and blow through the contractions." From my position, it wouldn't have embarrassed you (as a student you wanted to help but needed to be coached through the process of a precipitious birth if that's what was happening). This is how students learn.

IMH pre-nursing student opinion, the preceptor should have told you to help mom blow and pant through the contractions (instead of pushing) which might have slowed everything down. It sounds as if they may want to point fingers at someone, it sounds like.

I'm so sorry that this happened to you, and I really hope that everything turns out OK. :)

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Sounds to me like the typical L&D game of finger pointing is going on. If you, as the intern had erroneously told the patient to push, why couldn't the doctor and the nurse in the room say, "No, wait, don't push."

This isn't your fault. Period.

Altalorraine

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Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

If you, as the intern had erroneously told the patient to push, why couldn't the doctor and the nurse in the room say, "No, wait, don't push."

I'm not an L&D nurse either, but I wondered the same thing. That's part of the RN's job with you, is to teach you what to do and what not to do. The nurse has the experience to know that the delivery might not go perfectly smoothly with this particular patient; you don't.

This was not the first person to tear while delivering, and won't be the last. In any case, the nurse could've yelled for her to stop pushing and apparently didn't. Not fair to blame the student for that.

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Specializes in Maternal - Child Health.

Please don't misunderstand what I am about to post. I am not, in any way, trying to demean your role as a student intern. You are a valuable asset to your unit.

However in this situation, you were the only UNLICENSED member of the healthcare team present at the patient's bedside. How in the world this RN intends to place blame on you for a possible cervical laceration is way beyond me. Your role is to assist and learn. The staff nurse and physician are responsible for directing you. If you made an error in guiding the patient, one or both of them should have tactfully spoken up immediately.

Don't allow this twit to undermine you.

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First off, I hate directed pushing if mom obviously knows what she is doing, so I am biased here :) I am a student nurse, doula, and mommy.

Many would argue that she was better off tearing than having an epis. If she would have had a cut there anyway and she tore and has no pain or swelling, what's the difference? Especially when current research suggests tearing is better than cutting.

As far as telling her not to push, from personal experience, I wouldn't have listened to you. If baby was coming, baby was coming. She may not have been able to control it.

It sounds like your preceptor has certain ways she does things and she doesn't like to depart from that. It sounds like you were competent and in control of the situation and she didn't like that. It also sounds like what you did was supportive of mom and best for baby and maybe some of that doc/nurse's practices are not in line with that.

I bet if you could ask the mom she would say she loved your support and is happy with how things worked out.

FWIW, I had 2nd degree tears with both my babes, little pain, little swelling, and I would have kicked anyone who came near my perineum with scissors:)

Best wishes to you and don't let this butthead get you down.

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Specializes in L&D.

Thanks everyone for the input. I'm feeling a lot better about everything that happened. I, too, don't subscribe to the "episiotomy is always better than a natural laceration" mindset. The RN who I was working that day is usually very supportive. Maybe she was bearing the wrath of the MD and decided to pass it along to me. Oh well, I guess you live and learn.

Nikki

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