Great Delivery / Bad Delivery

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It's been almost 24 hours now since my last shift and I am still overwhelmed by the events of the day. Some background ... I'm a new grad in L&D and am on my 10th week of training with a very knowledgable and skilled preceptor.

The day started great with a primip at 7cm when we arrived and delivered several hours later after only an hour of pushing. My preceptor let me run the show and I asked her to only step forward if something I did (or did not do) would caue harm to the patient. She didn't need to tell me anything and it went smoothly ... the doc even told me "good job".

We recover this delivery and move on to the next patient. This patient has been passed around to three different nurse by the time we get her so we ask all nurses involved for report and background and proceed from there. Loveyly primip with a supportive husband and family. She went into early labor at 35 weeks and was given Nifedipine only to have it cause a horrible rash. Docs apparently decided to let her go ahead and labor and she is not 35 6/7. She goes from 4 to 7 with a little help from some Pit (only ever up to 2mu) and Stadol. Stadol knocks her out between UCs but she breathes beautifully with each UC. Her GBS status is "unknown" and I ask if we hang abx prophylactically and my preceptor tells me that if the doc wanted it, he would've asked for it. Doc comes by at 1730, SVE 7/100/0. She gets another dose of 2mg of Stadol and I'm in there every 15 minutes reading the strip and charting and talking with pt and family. At 1815 she's breathing well with UCs, denies rectal pressure. At 1823, mom comes running out saying she's pushing just as we notice the change on the strip at the nurses station. We go in, my preceptor asks her to roll over and when she does there is a baby crowning. I throw gloves on and put my hands down there why directing to her pant like crazy. She can't and she's pushing this baby out. I have the head out as the doc runs in and delivers the rest. He does not stimulate, cuts the cord, then passes her to us as my preceptor calls the NICU to come. They get there at 2 minutes of life while we are stimulating and trying to count a heart rate. My preceptor had stopped stimulating the back so that I could count a HR when NICU arrives and they yell at us for not stimulating this baby. Baby is taken to NICU with apgars of 5 and 7 and weighs 3lbs 7oz.

I am at this point cleaning up mom while trying to chart. Doc is at nurses station upset with my preceptor and me for not notifying NICU sooner and for not telling him she is GBS unknown. We pull out P&P and sure enough, an unknown should be treated with abx. We should not have assumed he knew about her GBS status, that was a big mistake. He's upset about the NICU thing but we called them AFTER we got him in the room (Doc should be there before NICU was our thinking) and it all just happened so fast that it was hard for me to process the situation. NICU is bitching to everyone that will listen that we should've called them sooner.

Whew! If you are still reading, thank you, because I am still overwhelmed and probably have forgotten some details. I guess I've learned to NEVER assume that a doctor knows something as important as GBS status. And NICU should be notified of an impending delivery way ahead of time so that they know what they are running to. I don't know what I'd do different ... thank God I set the table when she was 7cm ... I really didn't expect her to even deliver on my shift. And I sure didn't expect a baby that small.

Comment, opinions, advice is welcome ... I'm so glad we have this place to share ... just writing all of this out has made me feel better. Days like this are scary for me as a new grad and I am so thankful that I wasn't already on my own ... 16 weeks of training doesn't seem like enough anymore! I know I'll be a great L&D RN someday but today is not a day that I feel that way. :(

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Specializes in Med-Surg, Psych.

(((HUGS)))

Thank you for taking the time to share your day with us. I'm sure an experienced L&D RN will be along shortly to offer advice and support.

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Specializes in Med-Surg, OB/GYN, L/D, NBN.

FIRST of all....it is not your fault. You seem to be doing well. :cool: However, your preceptor should have known that the mother needs prop abx if she is GBS unk (at my hosp they get two units of Pen G unless contraindicated i.e. allergy). :nono: Secondly, the doctor should have been reading the chart carefully enough to realize that she was GBS unk...true enough it should be caught by the nurse, it is legally ultimately the doctors resp to catch.

I can understand NICU's concern for the short notice (probably made them swallow their food quite a bit faster) but sh** happens! When things are going fast, you can't think of everything at once. :uhoh3: Some of the support staff there with y'all (i HOPE you weren't the only ones there) should have called for you. And you absolutely HAD to get a HR on the baby to tell if they were in distress or not...(stimulating a baby won't detect a heart defect or no heartbeat at all...taking the HR will)

Just take it in stride and next time you will handle it better (although I think this time was as good as it could have been for you). :yelclap: I have found in my experience that most L/D doctors are very fickle. :stone He will b**** today and be fine tomorrow. :nurse:

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Specializes in Perinatal, Education.

Take a deep breath and pat yourself on the back. You did just fine. These types of deliveries happen to even experienced nurses. We had one the other night with a small 35 weeker that was 7cm and then delivered shortly thereafter. She probably never did get to 10 because the baby was small enough to come before then.

People will ALWAYS second guess what you do if the outcome isn't perfect. You will second guess yourself as well. You will also learn from your mistakes. It sounds like you are well on your way to being a terrific OB nurse.

I am always a bit concerned with report that tells me the doc has been informed or assuming the doc has decided not to order something I feel should be ordered unless it is documented in the chart that the conversation took place and what the doc's decision was: Dr M contacted regarding status GBS unknown. Dr. M declines to order Abx at this time. Or something to that extent.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Wow. I can see your frustration. Well, since the P & P contained this tx....that was definitely not followed.

I think that I would have alerted NICU early on regarding the fact you had a 35 weeker in active labor.

Things like this do occur and are most unfortunate.

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Thanks for the support and replies so far ... I definitely feel like some mistakes were made but I have also learned from them ... I know getting everything right in L&D is a long process but sometimes I just wish I could learn it all right now!!!! I'm hoping it doesn't turn into a huge issue at the hospital but maybe a reminder note to all L&D nurses about abx tx for unknown GBS status wouldn't hurt. I've got to find something positive in this situation!!

Thanks again for taking to time to read and offer up your comments! :)

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Thanks for the support and replies so far ... I definitely feel like some mistakes were made but I have also learned from them ... I know getting everything right in L&D is a long process but sometimes I just wish I could learn it all right now!!!! I'm hoping it doesn't turn into a huge issue at the hospital but maybe a reminder note to all L&D nurses about abx tx for unknown GBS status wouldn't hurt. I've got to find something positive in this situation!!

Thanks again for taking to time to read and offer up your comments! :)

I believe you did a good job with your patient. I am not so sure about the preceptor, however.

Experience is the best teacher. You will have many, many, many days in OB of doubt and heartache. But, you will have a lifetime of satisfaction in knowing that you are a good, if not GREAT OB nurse.

Keep up the good work.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

I think you performed admirably.

My best advice in situations like this is simple:

When the adrenalin wears off, and you can think more clearly:

1. Pat yourself on the back for the things you KNOW you did well! Go over what went 'right" in each situation, and be sure to congratulate yourself on a job well-done.

2. For the things you feel you could have done better, ask yourself how, and what you will do differently next time. A "debriefing" is always helpful, either in your mind or boucing off w/a colleague. Find someone you trust, whom you admire and bounce these things off him/her. Be honest w/yourself and resolve to learn from any mistakes you have made. We all make them and we learn to move on----get back on that horse and ride again.

Again, seems to me, you did a great job. Pat yourself on the back, put your feet up, and enjoy some well-deserved rest. Welcome to OB; it's quite a bumpy ride at times, but WELL worth it!

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I agree with SBE. Think of what you know you did well. Take time to debrief. No what to do differently next time.

IMO, your preceptor should have been a bit more helpful, as in, NICU should have been aware that a 35 weeker was in active labor (and on Pit :uhoh21: ), and she should have known it's P&P to treat unknown GBS status regardless of a written order. Yes, the doc should have been aware, but saying if he wanted it he would have ordered it was poor judgement beyond not knowing your own protocol, IMO.

As this baby was delivering, your preceptor should have been on the call light, having someone else call for NICU. And when you say stimulating baby, was that just tactile stimulation? Did you try O2, were you moving on to PPV? By 2 minutes, you should know if your baby is in primary or secondary apnea, kwim? If it's secondary, no amount of stimulation is going to help if you're not ventilating with O2.

Chalk it up to experience. We all have learning days. :wink2:

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Specializes in Nurse Manager, Labor and Delivery.

Honey, some days just go like that. It sounds to me like you did everything right..for the circumstances that you had at hand. Of course in hindsight you can see things that should have been done, but you kept your patients safe at the time.

My question I guess is....why didn't the doctor know she was GBS unknown? Did he not read the chart? Do you have standing orders to hang antibiotics for all GBS+ and unknowns

I don't have the NICU bonus at my hospital, so resusitating that baby would've been on me anyway. You didn't know she was going to deliver as she did, and could not possibly have called NICU to give them heads up. However, I am assuming they were notified of preterm delivery when she was admitted? And, someone else not involved certainly could've called them.

Folks seem to always pick when stuff happens like this. Hindsight is 20/20 you know. You did good, sister. Chalk it up and put it in the experience column and learn from it. It won't be your first, and certainly not your last.

Doesn't always seem to happen at the end of a shift???????

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The only way to learn is through experience. And I bet you will always check with the docs about GBS/tx from now on. Also it has been my experience that the NICU blames the L/D nurse for everything, and they are not shy about it. They don't get what we do before the baby is born, or what it is like to have the kid crowning with no help in the room. You did the best you could with what you had.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

I don't want to get into a NICU versus L/D thing here-----it goes both ways....really.

Having done nursery and L/D I do see both sides.

Again, lessons learned. We ALL have made similar mistakes or oversights. If we learn from them, we are better for it. The ones who don't, are the ones who are dangerous.

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