Going up against a doc...

Elvish, BSN, DNP, RN, NP · Feb 14, 2008

I know a lot of nurses who fudge dilatation to keep the doc out of there.

This fudging goes both ways - either saying she's ant lip when she's really complete so they're not in there insisting that she push, or saying that she's really further along than she is (as long as baby looks ok, of course) to keep her out of the OR.

**canoehead, BSN, RN** · Feb 14, 2008

Make it a policy to check the woman after the doc says something like that. You may not agree on cms but you can certainly tell the difference between changed/not changed. When he brings up the C section you don't need to contradict him- but mention some other finding, like the head is lower, or ctx are more regular, or we could still try x, y, z so the family knows the section isn't the only option.

ragingmomster, BSN, MSN, RN · Feb 14, 2008

mention some other finding, like the head is lower, or ctx are more regular, or we could still try x, y, z so the family knows the section isn't the only option.

All good suggestions, thanks!

rpbear · Feb 16, 2008

I liked the policy at one hospital I worked at, I order to call it failure to progress, they had to have an IUPC, the MVU's must be 180-200 for 2 hours with no change. I think this is a great way to trully say they are failure to progress. If the IUPC was placed and the MVU's were only 120, then you know that the contractions are not strong enough to produce change. Of course there are situations that this was not possible, but it took a lot of the questions out of the situation.

micmac · Mar 13, 2008

We had to fudge our exams a lot until the docs bought into the idea of laboring down...thank god they finally got what we had been doing all along!

rnjustld · Mar 14, 2008

Anyone else had experience with OBs saying "I'm going to check this patient now and in an hour and if there is no change we are sectioning her," and then wondering about the doc lying? I was in this situation the other day and it put me in a horrible spot and when I mentioned it to another nurse I work with she said that at least two of the OBs she knows does that to get someone sectioned when they want to get outta there :angryfire.
I am relatively new (new grad-- 8 months in L&D on a unit that does about 1200 births a year) and I don't feel completely secure in my cervical checks all the time. I feel like if I did-- if I had been there longer, I could have felt confident in standing up to this doc more. As another nurse said "you would be blacklisted," but I don't care-- I'm not there to work in the docs best interest, but its such a hard situation.

Can u get any of the more experienced nurses to check with u before c/s is called? She would be better able to stand up to the docs. I have found though that docs either trust your judgement, or dont, or just think their judgement is the only that is true. Lots of lot. I love labor & delivery even with all the ups and downs and extreme challenges that come with it daily.

Kristin_collegemom · Mar 15, 2008

Yes!! I've only been in L&D about 9 months... and let me just say my hospital has WONDERFUL OB's... but I did have a dr. a few months ago say the same thing that doc said to you.... about 45 minutes later the pt called out and said she was feeling pressure... so I checked and said to her, "well the baby isn't coming now, but you're definitely not 4cm anymore! You're a good six!" so the MD comes in 20 minutes later, does an exam and in front of the pt "Kristin, I think you need to put on a glove so we can calibrate our exams. your 6 is definitely my 4..." I have taped a little ruler to the back of my badge and I know the difference between a good 6 and a 4... so anyway, I put on a glove, check the pt while she stands there and says, "see she's really a 4 isn't she?" No joke! "shave her for her section"

I also had another dr. tell me (when referring to another rn's cx exam that I had just gotten report on who was 8/100/0) "well she's definitely 7cm and 90%... and not to sound snotty, but my exam is the only one that counts!"

So yes, md's do this! They "fudge" their exams so they can go home... But, I find the nurses that are very experienced don't say anything to our docs, and they don't try to pull that crap with them either!

micmac · Mar 15, 2008

Yes!! I've only been in L&D about 9 months... and let me just say my hospital has WONDERFUL OB's... but I did have a dr. a few months ago say the same thing that doc said to you.... about 45 minutes later the pt called out and said she was feeling pressure... so I checked and said to her, "well the baby isn't coming now, but you're definitely not 4cm anymore! You're a good six!" so the MD comes in 20 minutes later, does an exam and in front of the pt "Kristin, I think you need to put on a glove so we can calibrate our exams. your 6 is definitely my 4..." I have taped a little ruler to the back of my badge and I know the difference between a good 6 and a 4... so anyway, I put on a glove, check the pt while she stands there and says, "see she's really a 4 isn't she?" No joke! "shave her for her section"
I also had another dr. tell me (when referring to another rn's cx exam that I had just gotten report on who was 8/100/0) "well she's definitely 7cm and 90%... and not to sound snotty, but my exam is the only one that counts!"
So yes, md's do this! They "fudge" their exams so they can go home... But, I find the nurses that are very experienced don't say anything to our docs, and they don't try to pull that crap with them either!

Oh, Kristin, that made my stomach hurt. I hate stuff like that...when they pull rank and humiliate you...especially in front of a pt. I have taken a provider aside and said, "We may have our differences, but please don't affect the relationship that I've established with the pt. by ruining her confidence in me!" Cervical exams can be soooo frustrating because it is so subjective. I like working at night because I don't have the providers mucking around in there so much. As far as I'm concerned, the numbers don't matter...as long as they are making progress.

Good for you for sticking with it...those kinds of things can make or break one's self-confidence and even after 10 years I still have episodes that make me question my own judgment. A wise nurse once said to always trust my gut and I try to remember that all the time. :bow:

Kristin_collegemom · Mar 15, 2008

Oh, Kristin, that made my stomach hurt. I hate stuff like that...when they pull rank and humiliate you...especially in front of a pt. I have taken a provider aside and said, "We may have our differences, but please don't affect the relationship that I've established with the pt. by ruining her confidence in me!" Cervical exams can be soooo frustrating because it is so subjective. I like working at night because I don't have the providers mucking around in there so much. As far as I'm concerned, the numbers don't matter...as long as they are making progress.
Good for you for sticking with it...those kinds of things can make or break one's self-confidence and even after 10 years I still have episodes that make me question my own judgment. A wise nurse once said to always trust my gut and I try to remember that all the time.

eh... It's not that bad!! I am confident in my exams, and if I am questioning myself I'll have another nurse check behind me... At least I'm not the 1 or 2 dr.'s no one wants to work with! And it's funny that that one dr. who didn't like my exam... I never hear her pt's rave about how wonderful she is... hmmmmm.... :) It's not me!! My patients like me! :up:

PegRNBSN · Mar 17, 2008

I believe that stooping to subterfuge is just as bad for nursing as doctors. I always try to communicate as the professional I am and want to be treated like.

If the patient hasn't changed and I am afraid the doctor will try to section, I would NEVER lie about a VE. I would state my reasons or plan for helping this woman obtain a lady partsl delivery. The MD is ultimately responsible and they deserve accurate professional information and communication from me.

Using the SBAR is a great way to communicate this

Example

S (Situation) Your patient Mrs Jones' last VE was unchanged at 4cm

B (Background) Her contraction pattern was irregular for the last two hours and she was very tense with contractions

A (Assessment) She had an ineffective labor pattern and poor pain relief

R (Recommendation) I think she would benefit from some IV pain meds which she is requesting and she is open to Pitocin augmentation (or other interventions which you would like to recommend to MD)

Much better than lying about a VE.

I know there are many MDs who will not respond well but we need to be take the high road in professional communication:)

NurseNora, BSN, RN · Mar 17, 2008

I really like your use of the SBAR. You gave a very clear example of how to use this tool in communicating effectively with your provider. I still hear nurses hinting vaguely to the MD what they would like to do to help the patient; often so vaguely that the MD totally misses the hint.

I think I'll print up your post and hang it up at work as a good example of how to use the SBAR when communicating with the doctor.

Thanks