Help!!

Elvish, BSN, DNP, RN, NP · Oct 2, 2008

Vag exams every half hour is excessive.

1) Increased risk of infection

2) Cervical edema

3) Annoying and uncomfortable for mom.

Those orders sound really really out there. And it doesn't sound like chain-of-command is going to be so helpful. I'm sorry you're stuck in such a predicament. I would definitely let every patient you take care of that the doc wants a half-hourly vag exam and that they (the pt) have the right to refuse. I absolutely would if I were a patient. That is just ridiculous. :madface:

And, I can see a lot of cervical edema = failure to progress = c/s in the future. That is definitely a big :down: . Hugs to you because you sound very frustrated, as would we all.

Jolie, BSN · Oct 2, 2008

I'm sure you can find AWHONN and ACOG standards that contradict this ridiculous order for every 30 minute vag exams, not to mention that patients have the right to refuse. If I were a nurse caring for one of this doc's patients, I would be tempted to say "Your physician wants me to conduct an uncomfortable and possibly dangerous lady partsl exam every 30 minutes so that she can stay home for the duration of your labor and arrive just in time to catch your baby. Do you want me to do that?"

Also, if this doc wants hourly updates on her patients, she can pick up the phone and call you.

LNDis4ME · Oct 2, 2008

I had a somewhat similar situation on my unit last nite:

G2P1 came in with c/o contractions. RN does exam and calls it 3-4 cms. This particular pt had been d/c'd earlier in the day for same complaint-she was checked by HO who called her a FT. Upon readmission, HO again checks pt and says 2 cms. Pt goes into jacuzzi, gets out, SROM and all hell breaks loose---she's pushy and just wild with 1-3 min contx. Another RN checks her and says 5-6cm. Attending and anesthesia is called in for epid. Attending comes in @2200, checks her and says 4cm. Thankfully there was no witch hunt or screaming involved blaming anyone for an inaccurate exam, but of course, everyone is kind of looking at each other trying to figure out WHO must have been off on their exam? FT...2cm...3-4cm...5-6 cm....4????

So, I come in at 2300, the delivery table is outside the door, pt has epidural on board, and we are all ready to have a baby. I assume care of the pt, pt is acting VERY transitiony...vomiting, sweating, shaking etc. I check her cervix at 2330 and what I found was the downright most weirdest thing I can recall...her cervix...bilaterally and posteriorly was about 4-5 cms, HOWEVER anteriorly there was this HUGE mass! I actually started to withdraw my hand and then rechecked thinking perhaps I was feeling a presenting fetal hand, but it was just soft swollen tissue. Very hard to describe, but that's the closest thing I can compare it to! Of course, I asked the pt if she'd ever had a procedure such as a leep or cervical lac with her last delivery (thinking scar tissue) but she denied.

Anyhow, this ended up dragging on all nite...she did gradually progress slowly and was a rim when I left this am, I won't go into all the gory details about how her epid. didn't take and we repeated 2 more times. Her transition SX also continued until I gave her some stadol and phen @ 0230. I did have the attending check her behind me several times just to confirm what I was feeling...he did even try @ 0430 to slip it over, but to no avail, so we repeated the epid. a 3rd time with success. The OB, the HO and myself all kinda stood around all nite trying to figure out why we didn't have a baby yet? It was bizarre. And yes, we could have started pit, but she was contracting 1-3 on her own.

So my gut feeling on this...I do think that the pt was indeed 5-6 cms at some point last evening, especially b/c of the symptoms she displayed....however, b/c she was involuntarily pushing too soon, this caused cervical edema, which caused the "backwards" progression" to 4 cm. I also had a suspicion that the baby may have been a bit acynclitic, but couldn't confirm this b/c she was so uncomfortable with exams and I didn't want to cause further edema. Once she was finally comfortable @ 05-0530, had a nap, she seemed to reach the point where the OB could finally slip the cervix @ 0730. I can't for the life of me figure out why it took this pt so long to progress, other then the edema and her pain level. It frustrated me to no end to not be able to deliver her, but it was a good learning experience...yes, pt's can actually go backward! I am also thankful, in light of the OP's post, that our docs are not the type to go screaming and crying to the NM or whoever b/c they didn't agree with an exam!

HR_LPN · Oct 3, 2008

Several times I've seen a bulging BOW cause a cervix to be 6 cm, then SROM, and...tada...4 cm. But I've never seen anything like you've described. Hmmm...

OzMW · Oct 3, 2008

Maybe someone should suggest she come in and provide continuous care for her patients if she doesn't trust the nursing staff. I would absolutely refuse to inflict this crap on patients. If she has such lack of trust in nursing staff then she should be doing the ve's herself. I imagine they wouldn't be getting done so frequently if they were fobbed off onto her. If everyone takes this stance surely they can't single anyone out.

MIcrunchyRN · Oct 3, 2008

LOL I could say as a laboring mom I would NEVER allow a doc to check me that much.. it really means nothing in the grand scheme of things. It increases risks of infection, its down right uncomfortable and really who wants someone playing around in their lady parts elbow deep every 30 minutes... let one one nurse... there would be 2!!!

As a nurse your responsible for your own license. If a doc ordered some high dose of some crazy drug you'd question them. This is no different and if doc is still demanding I'd refuse to do it. If you go up chain of command and STILL they want you to do it, I'd A) reconsider my job where I"m putting my patients at MORE risk of complications and C/S. Or I'd nod my head and smile and tell my patients what doc wants and remind them lots they can refuse at any time. Especially mama's who've had more than 1 will know better and anyone laboring without an epidural wouldn't let you touch them with a 10 foot pole.

crysobrn · Oct 3, 2008

Oh no. I also work in a small unit... The docs are occasionally NOT very fun to work with and since there are only 2 (right now anyway) it's not like you can get backup from a doc necessarily if you need it... Our director also has no clue about OB, the unit sort of fell in her lap so she is also not much help...

Fortunately for us, the docs realize that we can make their jobs easy or hard. I mean if one of them questions me about what I'm doing or my assessments, I have to ask them to come in... They cover call for themselves 24/7 so they either trust us or come in and check after us. There are no residents, no interns etc... We do our own checks, our own spec exams, sometimes end up delivering our own babies since we have no one in house... I'm guessing it's the same where you are.

As a pregnant woman myself I would never let a nurse check me every 30 minutes. I keep my checks to a minimum on my patients.

Not sure what else to say... Have any of the OB's been informed of the way this doc is treating the staff... Sometimes they can make more of a difference than the actual nursing staff. We did have a doc not too long ago that was seemingly bipolar. She'd order something and then deny it, she'd yell for no reason etc... We started having two nurses available for ALL orders as well as writing up every incident involving her. She eventually was asked to leave by the other OB's they were just sick of her being the way she was.

SmilingBluEyes · Oct 4, 2008

You received great responses. I can't add much at all. I just wish you the best. And please, please do tell the patients what their doctor is demanding (hourly cervical exams, example) and give them the right to refuse. There is NO evidence supporting such practices!