Great Delivery / Bad Delivery

fourbirds4me · Aug 27, 2005

Sounds like you performed to the best of your knowledge... However, remember that knowledge is power. Always know your P&P. Policy always overrides orders. Your hospital will not back you up if policy was not followed.

As to the resucitation...at my place we do not have a NICU and RT does not come to our deliveries. We resucitate our own babies and call nursery over (transfer) as needed. Again, if protocol was followed, sounds like you did the right thing. Only problem being if at two minutes you are still stimulating the infant. Was PPV being used? Was there spontaneous resp. What was the heart rate? Were you and your preceptor NRP certified? If not... get certified as others have said... you never know when a good strip is gonna produce a bad baby.

SC RN, RN · Aug 27, 2005

I'm off to work now but wanted to fill in a few details for those who've asked:

We give Stadol 2mg every 2 hours (if it's 1mg, they can have it q 1 hr).

Yes, we are all NRP certified. I just recently took it in June.

Thanks again for all of the support and comments. Here's hoping that today is a better day! :)

heyabo · Aug 27, 2005

I remember when I started in L&D, I had a pretermer go quick like yours and the same thing happened with NICU. there are so many htings you need to remember to do , that when you firsst start out things will get missed. One of the nurses who I was working with told me that it takes at least a year to get comfortable with L&D and she was right. POINTER never assume the Doctor knows everything. Think about howmuch time the RN is with the pt and how often we go thru their chart while she is in labor and compare to the amount of time the DOctor uses the chart. Good Luck with you training. it does get easier

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.

RNnL&D · Aug 29, 2005

I'm off to work now but wanted to fill in a few details for those who've asked:
We give Stadol 2mg every 2 hours (if it's 1mg, they can have it q 1 hr).

Wow! Your patients must be really comfortable. :bugeyes: I have only used Stadol twice, and IME, it will knock you on your butt. We use Nubain 5-10 q 2 hrs x 2. We do have a standing order for Stadol if Nubain isn't helping, but like I said, I have only used it twice, and it knocked both of those patients out.

SmilingBluEyes · Aug 29, 2005

I don't find Stadol worth a darn in pain control w/most my patients. Same thing w/Nubain. I find these are only really useful in therapeutic rest in early/prodromal labor. With all these meds, patients usually end up "foggy" or nauseated, but still feeling every contraction acutely. If a person is really wanting us to intervene for pain relief, I always recommend regional anesthesia. It's safer and more effective for a lot of reasons. If they insist on IV meds, however, they do get them, after all options are discussed.

RNnL&D · Aug 29, 2005

I don't find Stadol worth a darn in pain control w/most my patients. Same thing w/Nubain. I find these are only really useful in therapeutic rest in early/prodromal labor. With all these meds, patients usually end up "foggy" or nauseated, but still feeling every contraction acutely. If a person is really wanting us to intervene for pain relief, I always recommend regional anesthesia. It's safer and more effective for a lot of reasons. If they insist on IV meds, however, they do get them, after all options are discussed.

So true. I always let patients know that IV pain meds, are not going to take their pain away, merely help them relax in between contractions. The first dose of Nubain is the most effective if you can manage to give it at just the right time, which unfortunately, is different for different patients. After that, it's like a Bandaid on a broken leg.

Mississippi_RN · Aug 29, 2005

I don't find Stadol worth a darn in pain control w/most my patients. Same thing w/Nubain. I find these are only really useful in therapeutic rest in early/prodromal labor. With all these meds, patients usually end up "foggy" or nauseated, but still feeling every contraction acutely. If a person is really wanting us to intervene for pain relief, I always recommend regional anesthesia. It's safer and more effective for a lot of reasons. If they insist on IV meds, however, they do get them, after all options are discussed.

I agree... I had Stadol when I was 6 months pregnant and had a kidney stone and then again when I was about 3-4 centimeters waiting on my epidural. Both times all it did was make me burning hot :angryfire (like I was on fire from the inside out) and made me mean :nono: Didn't really help with pain at all.

ljds · Aug 31, 2005

At our birth center, we use the Stadol, but only in two situations. One is for rest, and the other is when the mother calls, says "Im in labor, and it hurts so bad, I want to go straight to the hospital for my epidural!" We usually can talk them into stopping by on their way in :) and trying half a mg of stadol. Usually that is all they need to get comfy and get on top of things.

Even then we only give Stadol about 4% of labors.

I work in an out of hospital situation, where we have one nurse and one mw. No routine line established, though mamas with GBS, PROM, or a hgb below 11 have a lock. In four years, only once have I had the situation where baby was a slow start, then mama started a pph. Amazingly, you rise to the occasion. You all can't imagine working without all your support staff, but you would do just fine if you didn't have them, because you rise to the occasion. I can't say I believe in a higher power; yet every time we've had some sort of emergency, we've had extra staff or amazing luck. The slow baby with the bleeding mom? Dad was an EMT, grandma was a midwife. Dad held the blow by O2 while I worked on baby and grandma and mw worked on mama. Our one emergent transfer for prolapse cord, the ambulance that got the call happened to be driving by our facility; from the time we diagnosed the prolapse to the babe being out was approximately 22 minutes, baby had apgars of 9/9/9/. (Helps to be across the street from the hospital...).

We're pretty blessed, though, because it is extremely rare for us to have a baby with a one minute apgar of 6 or less.

For the OP--live and learn. It's a scary thing, being human! Everyone messes up, or performs some duty in a less than perfect manner every dang day; but for people like us, there's a little more on the line, huh? It sounds like you did a fantastic job; your preceptor dropped the ball a bit, but really, everyone is human. Like many others have noted, you evalutate EACH DAY. What you did right, what you could have done better. It is as simple as that. Learn from your missteps, and pat yourself on the back for all the things you did well.

What a shift for you! Neat to catch, huh? My first catch was on the toilet (luckily MAMA was on the toilet, not me)! Mom was having UCs 8-15 minutes apart, but had a history of precipting. She went to the bathroom to urinate, feeling NO rectal pressure, and all of a sudden she's screaming "The baby's coming!" I ran in a caught, it was so fast, I couldn't think, just did. KWIM? That's a nice feeling.

You are doing a great job. Keep up the good work!

Lori

JaneRNBSN · Sep 3, 2005

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

To Miranda,

I worked in the OR and was constantly berated and humiliated by a few choice surgeons. I understood that, as a circulator, my responsibility was to keep the procedure running smoothly so that the pt. was under anesthesia for as little time as possible. If I held up a case, I understood why the doc was yelling at me. But one particular surgeon routinely charged through the door griping and yelling about every little thing he could think of, even the room temp! You made me realize that this guy is just plain scared!!! Thanks for a different spin on things.

sazeyplus2 · Sep 4, 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.

Sounds like quite a delivery! I am also an L&D new grad nurse in my 7th week of training. I know this at least- your preceptor should have told the Dr. about he GBS status, and anticipated that he would absolutely want to hang abx. I'm really surprised your preceptor didn't know the p&p on this. Second, your preceptor should have known w/a pretermer, NICU should have been notified first- and by 8cm at least. :nono:

It sounds as if you did great and learned some lessons you (or your preceptor) won't soon forget! I'm reallyy impressed with all you did as a new grad: trying to hold the head in and counting heartrate in such a stressful situation shows you already have a good foundation. Thanks for sharing your experience!

Editorial Team / Admin · Sep 4, 2005

trying to hold the head in

????????? :eek: :eek: :eek: :eek: :stone

sazeyplus2 · Sep 6, 2005

????????? :stone

What I meant was, she put her hand up to support the head so it didn't come shooting out. Didn't think it was that confusing to warrent all the faces...