Help me analyze this delivery...

[shortstuff31117]

Pt. comes in about 3 am in active labor, SROMd, 6-7 cm. Second baby, history of 1.5 hr labor. I call doctor and suggest she be on her way. Pt. doesn't want epidural, which is fine with me (doctor doesnt like it but whatever). Pt. is complete around an hour or so later and pushing. Heart tones go into the 90s-low 100s with good variability. Other nurse working with me checks and thinks baby is OP so starts helping to rotate baby. Encourages pt. saying good pushing, baby is rotating! Pt. is pushing well at this point, not tensing or anything.

After just a couple minutes, the doctor walks in, looks at the pt. and yells "Your baby doesnt like this, you have to push him out now!"

The pt. immediately tensed up and pushed but was totally fighting the pushes. Doctor continues to yell at her, basically scaring the crap out of her. When it had been maybe 10 min of pushing, the doctor screams out to get anesthesia here, that we may need to do a crash section! All this time the heart rate has remained in the 90s - low 100s. About this time she puts on a vacuum and finally pulls the kid out, with the worst vacuum marks I have ever seen. Luckily the baby was fine, screamed right away.

I have seen quite a few deliveries where the baby drops their heart rate like this, but never have I seen a doctor freak out like this!

Has anyone else experienced this? Was this doctor way out of line?

[PegRNBSN]

Yep its totally passive aggressive.

I'm glade you work with docs that don't hold it against you if you institute chain of command. I'm also glad that you commonly agree with their POC. I however don't have that luxury. I work with some good docs and some bad ones and even the good ones have bad days were they are tired or make mistakes.

If I have to be passive aggressive to keep bad stuff from happening I will. I have seen horrible things happen because doc's are in hurry and I have seen good nurses challenge them and have seen those nurses hit the street for it.

Yeah I'm passive aggressive but I will never see another bottom ripped to a 4th or a patient who needs suturing b4 delivery because of docs wanting to get home for dinner. I also would rather not lose my job fighting a loosing battle. So call me passive aggressive if ya like, I can't deny it. I can say that it is effective and that docs don't get away with unnecessary interventions nearly as often as they used to with me.

Also the phsician is not ultimatly responsible for the care of the patient, we are suposed to work colabratively but thats doesnt always happen. If you ahve ever been to court you find out that the psyican is ultimatly responsible for very littel adn if the lawyer wants to get you all he has to do is bring up your responsibilty to advocate for a patient. "if you didnt agree why did you let them do it?". Vacume is a medical desition but we still ahve a responsibility to not participate in things we see as unsafe. However when you have a disagreement with a doctor you quickly find out that hospitals dont care. so passive agressive is all thats left

Also a 41 6/7 weeker? Omg that's the problem right there as much as I hate inductions, there are reasons to induce and a patient reaching 42 weeks is pretty risky.

Can I ask where you work? Don't have to be specific but how many deliveries does you hospital do? What part of the country is it?

Work in the Midwest, 3000 deliveries a year. Level 3 hospital, full time perinatologists.

Actually the midwife group who was inducing this patient induces between 41 and 42 weeks all the time. Well within the standard of practice. Baby looked great when admitted. Problem ultimately was chorio.

I am lucky because we have very good doctors and a very active medical QA that gets rid of dangerous physicians. They are very open and eager to hear concerns from nursing. I guess that is the mindset that I am coming from.

We have monthly strip reviews with both nursing and docs with the perinatologist. Poor treatment of nurses or patients is addressed by the chair of the department.

I guess I am lucky.

When I was saying that the doc is ultimately responsible, I was referring to the fact that in this case while the MD was escalating things verbally, using a vacuum in this situation would not be considered out of line, while withholding the vacuum could be.

[Dayray, RN]

yeah that sounds really nice wish it were that way here. Ive gone to manager about MDs and she says "there really isent anythign we can do". I sugesteed chain of command up to the head OB (a doc) and haveing him come in and see the things that happen with a particular MD. She warned me and was right, they wont do anything not worth stickign your neck out that way.

Ive seen some bad stuff go to risk managment comity (which is made up of the OBs thta practice at this hospital) they always say that the MD acted apropratly.

The differance is made by good Rns who know how to handel OB's. I feel bad for patient's who get the new nurses or the ones who dont care. After a while you learn to handle things so bad stuff doesent happen but you dont have to go u agisnt the MD.

been thinking of leaving and hearing of places that are goverened by standards other then docs covering for other docs gives me hope.

[Dayray, RN]

Oh btw , not saying anythign bad about midwives practice. I know some providors are still letting ppl gp to 42 weeks. Im kinda torn as to an opinion on the practice. Like i said I really hate inductions, but those old placentas scare me.

[PegRNBSN]

Oh btw , not saying anythign bad about midwives practice. I know some providors are still letting ppl gp to 42 weeks. Im kinda torn as to an opinion on the practice. Like i said I really hate inductions, but those old placentas scare me.

As long as there is proper testing from 40 plus weeks I am okay with 42 week inductions. They are usually 41 plus inductions. This midwife group will induce earlier if the NST looks anything but beautiful.