G1PO INDUCTIONS

Editorial Team / Admin · Jan 10, 2016

Does your facility have an anonymous hotline where you can call to report this? Mine does, and we recently went through this with a few of our more questionable surgeons. Once it's reported, it is taken seriously. Venting here or to coworkers doesn't set the ball in motion for a definitive investigation.

NurseNora, BSN, RN · Jan 11, 2016

AWHONN recommends not doing elective inductions before 39 weeks. My hospital had a doc very like this one (I've seen him do amniocentesis for lung maturity for elective inductions) who actually left for another facility after our Director worked very hard to get this policy implemented. Investigate AWHONN's "Go the Full Forty" program and see if you can get your department leaders involved in making changes. I know this patient was beyond 39 weeks, but her Bishop score was pretty low. Advocate for including a Bishop Score of >7 for elective inductions in your departmental policy.

Discuss your concerns about this case with your Director. Write incident reports on elective inductions with outcomes like this. What were the Apgars? A low Apgar is an outcome that have an incident report anyway. Get the patient handouts from the Go the Full Forty program (AWHONN.org) and pass them out to every triage patient that is sent home. Discuss options with patients abour cervical ripening before Pit for those who choose elective induction anyway. Find out what your patients know about inductions and why they are being induced (So why are you being induced today?" "I don't know, the doctor just told me to come in and have the baby today.") Many places are starting to require consents for induction; consents that have risks as well as benefits. Join AWHONN and attend conferences and workshops. Not only will you learn things, you will have a chance to network with other nurses and brainstorm common problems and solutions.

Good luck.

offlabel · Jan 11, 2016

Very frustrating indeed. Nothing like placing a labor epidural in the patient you describe at 10 am knowing full well that at some time after midnight, the pager well be going off for a hurry up section. I'd rather do it at 10 am. Better looking baby, too.

SoldierNurse22, BSN, RN · Jan 11, 2016

Because we had a certain group of docs who liked to do this at my work (and one very charismatic, well-liked who still does), we recently instituted a policy at my facility.

No inductions before 39 weeks for ANY reason other than medical.

Elective inductions MUST have a favorable Bishop score from the MD to be referred for an induction. In order to proceed, the patient must have a favorable Bishop score based on the RN's assessment. If the RN finds the Bishop score to be unfavorable, the charge nurse takes it up with the doc. If the doc has an issue with it, our manager talks with the doc. If the doc still wants to induce and finds a way to weasel the induction into a medical induction, then the doc has to come in and do a full H&P, otherwise, no dice. The patient packs up and heads home.

Many of the main offenders (like the horrible OB in your story) have started going to other hospitals. Good riddance.

Y'know, while I certainly hold the OBs accountable for influencing the decisions and opinions of their patients, you have to admit that a bit of blame belongs on the patients, too. In this day and age of accessible and trustworthy medical info, if they don't know better as competent, intelligent adults, well...yeah. I'm not saying it's their fault entirely by any means. I mean, how do you tell someone you shouldn't always trust your doctor? I wish there were reputable sources that told women and their partners how to spot these types of physicians and how to say no in a safe, legal way. It would be a different kind of job.

SoldierNurse22, BSN, RN · Jan 11, 2016

To follow up to your story and springboard off my previous post, I had a patient a few months back who was admitted for an elective IOL at 39 weeks. She was a G1P0 and had a borderline favorable cervix, but overall, I felt it was probably best to wait, especially because her Bishop score was close to favorable, but it was definitely not good enough to indicate induction under our new policy. My charge checked her and fudged the numbers a bit, I think because she didn't feel like going toe to toe with the doc that morning.

After my charge nurse left, I did exactly what you did. I advocated for my patient. I told her that if she kept her water intact, she could opt out of the induction at any time. I told her she could refuse an AROM and to make sure she stated to the doc that she didn't want to be AROM'd with a nurse witness present.

Anyway, I left for the day and came back that night just as they were taking this patient back for a stat C-section for fetal distress and failure to descend. Apparently, baby had been having lates all day. They AROM'd mom when she was 2 cm and ballotable.

As the icing on the cake, the doc had the gall to be in a huff and all pissed off that she had to section this lady because it was the doc's husband's birthday, and she was supposed to be eating out with him that night. Nevermind that this poor lady just had an unnecessary c/s because her doctor is a selfish, sad excuse for a human being. Nope, she was all mad because of the missed birthday dinner.

OK, then don't set up an unfavorable G1P0 for an elective induction the morning of your husband's birthday and expect to be footloose and fancy-free that evening, you moron!

UGH.

**LibraSunCNM, BSN, MSN, CNM** · Jan 12, 2016

Great comments by all. I like the idea of handing out literature to women in triage with the current evidence. My workplace has a LOT of shortcomings, but I am really grateful that one thing we do right is NO elective inductions whatsoever.

Surfandnurse · Jan 12, 2016

Thank you all for the insight and support! I am traveling at this institution, but have discussed these issues with permanent staff. They have a brand new nurse manager,tho, and I think at least more pt teaching regarding risks and giving the full fourty hand out at triage is such a grrrrrreat harmless idea! Ahhh I have some work to do!

SoldierNurse22, BSN, RN · Jan 12, 2016

Great comments by all. I like the idea of handing out literature to women in triage with the current evidence. My workplace has a LOT of shortcomings, but I am really grateful that one thing we do right is NO elective inductions whatsoever.

Oh my gosh. Where do you work? I will move!!!

Elective IOLs are single-handedly the biggest reason that we struggle with staffing at my workplace. Sometimes, we have anywhere from 3-7 scheduled inductions per day, not to mention those patients who come in already in labor or with antepartum issues that end up getting admitted. And none of our staff from charge nurses to doctors to our managers encourage re-scheduling our elective IOLs, even when we have nurses mandated and we're offering incentive pay for people to come in on their days off! Ridiculous!!

**LibraSunCNM, BSN, MSN, CNM** · Jan 12, 2016

Oh my gosh. Where do you work? I will move!!!
Elective IOLs are single-handedly the biggest reason that we struggle with staffing at my workplace. Sometimes, we have anywhere from 3-7 scheduled inductions per day, not to mention those patients who come in already in labor or with antepartum issues that end up getting admitted. And none of our staff from charge nurses to doctors to our managers encourage re-scheduling our elective IOLs, even when we have nurses mandated and we're offering incentive pay for people to come in on their days off! Ridiculous!!

I work at a public hospital. All doctors and midwives are employees of the hospital, there are no private practices. We all work L&D shifts, there is no "call" for our individual patients. As such, we don't have the kind of nonsense you have to deal with in terms of births scheduled around MDs' lives. I think the rule against elective inductions is just from so long ago (before we starting giving everyone LARCs!) when the city hospitals were so busy, and has just kind of stayed our policy. Or sadly maybe it's because, as Medicaid patients, the hospital system cares a lot less about the patients' individual desires, because they have nowhere else to go. At any rate, this particular policy definitely helps us keep our section rate *slightly* lower than average, and is a real reason I stay there.

CBlover, BSN, RN · Jan 12, 2016

May I PM one of you about my recent delivery? It was pretty bad and I want to know what I could've done or MD could've done to prevent some things that happened. I wanted to ask a seasoned L/D nurse or midwife

ashleyisawesome, BSN, RN · Jan 12, 2016

Because we had a certain group of docs who liked to do this at my work (and one very charismatic, well-liked who still does), we recently instituted a policy at my facility.
No inductions before 39 weeks for ANY reason other than medical.

I find some of our OBs get around this by "making up" a medical reason. I saw this a lot right before Christmas (so they could deliver the majority of their babies between 12/20-12/23 and hopefully not have to be called in on the holiday). There were a lot of "unstable lie" dx for babies that were transverse weeks ago but have been vertex for a while, or GHTN for someone who had one or two semi high B/Ps in the office, but miraculously had normal b/ps all throughout labor for me! Also a few "possible macrosomia", and the baby came out 7lbs.