Great Delivery / Bad Delivery

rn/writer, RN · Aug 26, 2005

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.

the info regarding secondary apnea is right on target.

any time you end up in the soup with someone else yelling at you, take inventory later on and often you will find that the situation scared the bejabbers out of the yeller as much as it did you. it's kind of a default setting to convert fear to anger when you have to get control of something chaotic. doesn't make it right, but it has always helped me a little to understand this reflex. it would be nice if folks could go back after all the excitement has settled down and make amends, but that doesn't often happen. don't take it personally. sounds like you did a great job of handling a wild ride.

take care,

miranda

SC RN, RN · Aug 26, 2005

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:

Usually my preceptor is a by the book RN and she always has me looking up P&P whenever I ask a questions. I don't know why she was off her mark that day because she usually drives me crazy when I ask a question and she replies "what does P&P say to do"? She is excellent at making ME tell her what should be done and then either agrees with me or sends me back to P&P. It's a great way to learn in the end.

And, yes, we had 02 on the baby the second it was in the warmer .. she had it on the baby's face immediately and held it there during stimulation while I assessed the HR. I think we were doing everything right and would've moved on to the next necesary steps had NICU not arrived. By the way, baby responded quickly once they arrived and they had time to let mom see and touch baby before taking it to NICU so it was in no immediate distress at that point.

I have definitely learned from this situation and you can bet the same mistakes won't be made again (at least not by me). I know the old saying is "live and learn" but in L&D it can take on a whole other meaning. We don't alwaya have the chance to correct a mistake or turn things around. I'm glad this all worked out well in the end. Thanks for all of your input!!

Jolie, BSN · Aug 26, 2005

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.

You have learned, and will NEVER find yourself in these situations again! That's what orientation is for.

As a NICU nurse, I would like to add one thing: We know that **** happens unexpectedly! I can recall plenty of instances of moms laboring for hours, and then, bam!, delivering precipitously. (My self included, LOL!) My only request would be to have the L&D RN notify the NICU of the mom's presence on L&D, so that the warmer/stabilette and emergency supplies can be checked beforehand. It's no problem to rush into a delivery, that happens all the time. But it is a problem to rush into a delivery not knowing if the necessary equipment and meds are at the ready. That makes us very cranky! Thanks for listening.

allnurses Guide · Aug 26, 2005

We were talking at work yesterday about deliveries in larger hospitals and the amount of staff who come into the room. All the support staff that an L&D nurse has is amazing.

We deliver with one doc and one nurse. We don't do high-risk but then sometimes you just don't know ahead of time.

There is help available in other staff members if we get in trouble - and all our nurses, even the ones that don't do L&D are taking neonatal rescusitation class.

The nearest NICU is 70 miles away -

I think you did a good job - I always ask the doc if I can't find beta-strep info in the chart - even if they look at me like I'm nuts because they already know the status.

What about moms who just show up at your facility w/o any history and deliver quickly?

No one can read the future.

I learned a long time ago to have the room set up waaaay ahead of time - been surprised too many times, so good job with that too.

I agree with the poster who said the people who are complaining were probably scared too - a debriefing is a great idea.

steph

RNnL&D · Aug 26, 2005

We were talking at work yesterday about deliveries in larger hospitals and the amount of staff who come into the room. All the support staff that an L&D nurse has is amazing.
We deliver with one doc and one nurse. We don't do high-risk but then sometimes you just don't know ahead of time.
There is help available in other staff members if we get in trouble - and all our nurses, even the ones that don't do L&D are taking neonatal rescusitation class.
steph

All our nurses are required to have NRP..... L&D, PP, and SCN. NRP standards states one person should be at delivery who's sole responsibility is the baby. I remember delivering my first at a small community hospital with just the CNM and nurse though. Makes you wonder what would happen with a baby needing resuscitation and a mom bleeding out after delivery, kwim? I know there is generally someone available to come running in an emergency, but what if there wasn't? :uhoh21:

SmilingBluEyes · Aug 26, 2005

I would not be comfortable w/o a nurse dedicated to the baby.

have seen way too many situations take us by surprise-----"good baby on strip" become a 'bad baby" once delivered. Nope, no thanks. I have to concentrate on circulating the delivery and getting the dr what she needs----seeing to mom's needs to be that attentive to small changes in the transition period of the first few minutes......like observing for apneic spells or watching other things......I have a mom keeping me busy yet....esp if she begins to bleed etc.

We have two nurses at each delivery---and that is how I feel it should be.

SC RN, RN · Aug 26, 2005

I would not be comfortable w/o a nurse dedicated to the baby.
have seen way too many situations take us by surprise-----"good baby on strip" become a 'bad baby" once delivered. Nope, no thanks. I have to concentrate on circulating the delivery and getting the dr what she needs----seeing to mom's needs to be that attentive to small changes in the transition period of the first few minutes......like observing for apneic spells or watching other things......I have a mom keeping me busy yet....esp if she begins to bleed etc.
We have two nurses at each delivery---and that is how I feel it should be.

I feel that way too but I was always thought it was because I'm new and still don't know what I'm doing most of the time. Baby needs stimulation, apgars, clean dry blankets, vitals, clamp placed, and sometimes needs blow-by 02 or more. Mom meanwhile needs the pit going after placenta delivery and docs may need more supplies during suturing, mom can hemorrhage and needs to be watched, vitals need to be started on her. I feel like I am delaying care to one or the other during those first 10-15 minutes.

I know it will get easier but I'm still dreading going back in tomorrow and the next day. At least management is gone on the weekends so that brings the stress level down some. Oy Vey. I'm gonna need something to help me sleep tonight. :uhoh3:

SmilingBluEyes · Aug 26, 2005

All the "basics" can be taken of by one nurse, really-----if she is very efficient. But let one thing go wrong w/baby----let there be mec where there was none before----or some other complication, and you become very glad there is a nurse there to handle this apart from caring for mom and getting the dr's needs seen to.

RNnL&D · Aug 27, 2005

We have two nurses at each delivery---and that is how I feel it should be.

We always have two personnel at every delivery too. Usually a nurse and RT for baby, or two nurses if RT is at another delivery. I am busy attending Mom and assisting the doc as needed. If I didn't have another staff member to tend to baby, someone would be unattended at times.

Mississippi_RN · Aug 27, 2005

You have learned, and will NEVER find yourself in these situations again! That's what orientation is for.
As a NICU nurse, I would like to add one thing: We know that **** happens unexpectedly! I can recall plenty of instances of moms laboring for hours, and then, bam!, delivering precipitously. (My self included, LOL!) My only request would be to have the L&D RN notify the NICU of the mom's presence on L&D, so that the warmer/stabilette and emergency supplies can be checked beforehand. It's no problem to rush into a delivery, that happens all the time. But it is a problem to rush into a delivery not knowing if the necessary equipment and meds are at the ready. That makes us very cranky! Thanks for listening.

LOL...know exactly what you mean. I was working in the NBN Thursday and we were pretty quiet. We knew we had a couple being induced but nothing imminent. Anyway, all of a sudden we get a call from the L/D that we have a baby. Well, we did not even have a warmer on for cripes sake! So, we amble over to the warmer, get it on, set up an isolette with the D-stick, etc and I go towards L/D all the time thinking who went so fast?!? Well, here comes the L/D nurse IN with the baby wrapped up rubbing her all over telling her to "come on, come on". Well, I get a sick feeling cause I heard nothing..no cry, nothing. I go over to the warmer to help her with the baby and we finally get a cry. Well, the other RN came over and took over assessing the baby but asked me to go out and find out about the baby, since the L/D nurse said the cord ruptured before it was clamped. So, I go out to find out...come to find out, the mom delivered AT HOME and ambulance brought her and baby in... Well, I asked the Medic at the desk if the cord ruptured before or after clamped... He said before it was clamped and he did not know how. So, I go into ask the mom (she is getting the clotted placenta dug out of her) and she says that she cut the cord with scissors and then called 911. SHE CUT HER BABY'S LIFELINE WITH DIRTY, NONSTERILE SCISSORS WITHOUT TYING IT ANYWAY WHATSOEVER FIRST!! :uhoh3: :uhoh3:

*sigh*

Anyway, baby turned out ok... Hot for cocaine as was mom but otherwise ok... She was mom's #9...that we know of and she has custody of 0 (not this one either)... But anyway.....moral of the story that was a point I was trying to make... Not nice to be surprised like that and this was none of any the hospital employee's fault... (Well... MAYBE the ambulance could have called ahead but how many of them are going to?)

:chuckle

BETSRN · Aug 27, 2005

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.

First, I think you did a great job for where you are. However, I think at your stage of the orientation, your preceptor SHOULD have still been stepping in. Beta Strep status should be one of the FIRST things you check when you get a labor patient. Anyone under 36 weeks is unlikely to have had their final culture and you usually treat an unknown status with antibiotics. So, yes, your preceptor shold have asked you about that. Secondly, th doctor should ahve known to ask as well, if she/he had not reviewed the chart.

Where I am, we NEVER use Stadol in 2 mg increments: we only use 1 mg at a time.

Also (unless it is a precip), we always have a pedi at a preemie delivery.

Don't expect to even begin to feel comfortable in L&D for at least a year. You did fine! Best of luck!

allnurses Guide · Aug 27, 2005

We don't use Stadol at all.

Regarding more than one nurse -hey, I'd love that. But rural nursing and NO nurses available makes it a bit hard.

The supervisor who is also the ER nurse is also an OB nurse - so in an emergency she can come in to help with the baby or more likely we would pull a nurse from our acute station to be mom's nurse. Our docs are pretty awesome regarding aftercare of patients.

One doc cleans up the room and instruments so I can take care of the baby and mom. Even wipes up the floor.

I've had a mom hemorrhaging and a completely normal baby and had a RN run out for antibiotics for me and a CNA take care of the baby. If the baby was compromised, we would have another RN come.

As I mentioned, we don't do high-risk deliveries. But as you all know, you can't count on that.

There really isn't anything else we can do . . the nursing shortage coupled with the ratio law and the fact that we are rural and we can't recruit folks here all combine to make it hard to staff with more than one nurse.

steph