Need Honest Advice

[clb6885]

I am a new graduate L&D nurse. I have completed 12 wks of orientation on the day shift and was beginning to feel like I knew what I was doing.....I just completed my 2nd week of nights and I feel so lost. This week I had my first Mag patient. She was a 15y'o G1 P0 being induced. She was not given an enema before the induction began and she had several BM's throughout the night on a bedpan. After her epidural I checked her and she was 4cm and thin. (this was about 1045pm) At midnight, she stated she had to use the bathroom again. I put her on the bedpan for about 5 min. She had another BM. When I got her off the bedpan I checked her again.....10cm and crowning.....I immediately paged the Dr. (the dr's call time is

The pt was not in pain, but feeling the need to push w contractions. I was having her breathe through them and I held gentle pressure against the perineium. After several contractions she said she wasn't holding the baby in anymore and pushed the head out....at the very second the dr came in and delivered the baby and all was well.

Afterwards the charge nurse was mad at me and said there was no reason the pt should have preciped since she was a G1 with an epidural. I told the charge nurse what I had done and she said I should've crossed her legs and had her reinjected.

The next night the Dr asked me what had happened and I told her the story. I could tell she wasn't happy with me either. I told the Dr that I hadn't considered a reinjection bc the pt wasnt hurting, but I would know next time. The dr said that I didn't have to get a reinjection bc she responds to her calls quickly. I feel like such a failure.....what should I have done????

[tablefor9, RN]

"Cross her legs and get her reinjected"? WTH? Has your charge RN even *read* an article about precip deliveries in the last 20 years? And what color is the sky in her world? YOU DON'T EVER cross someone's legs...you've gotta be kidding.

Sounds like you did the right things and got caught in someone else's bad attitudes and ignorance, to me, but let's break it down...

1. Reinject...why? She wasn't hurting! No need to bolus an epidural.

2. Change cervix...great! That's kinda the point of induction, when last I looked. And, you checked her at appropriate times. She just went faster than your avg primip. Lucky her.

3. ENEMA? What? In the last 30 years? I don't think so. ICK and *totally* inappropriate. BM's are part of the package. We all poop, and laboring women do it more.

It takes a good year to be competent in a busy L&D. Ins and outs of triage, pt assessments, etc. Esp b/c you're a new grad. Hang in there, join AWHONN if you haven't already. Evidence Based Practice is your best friend. Because lawyers don't care if your charge RN said do it or the MD would be ticked if you didn't do it, when your actions are not up to standard.

Know your stuff, and with experience, it'll all come together!

HTH!

T

[NurseNora, BSN, RN]

I've noticed that just when a new nurse starts feeling comfortable and thinking that she may be getting the hang of this labor nursing stuff, something happens to take away all her confidence in herself and she starts feeling she'll never get it. So you're just exactly where you're supposed to be on your learning curve.

NEVER HAVE A PATIENT CROSS HER LEGS!!

Maybe next time you'll check the patient every time she says she need to have a BM. Or not. Your patient made unusually rapid progress. It happens with teenagers a lot. They take forever because their pelvis isn't all grown up yet, or they go unusually fast because their tissue is young and elastic. When a patient is being induced, they often go rapidly once the cervix is finally well effaced. Even knowing all of this, maybe I wouldn't have checked her that time either and she would have preciped on me.

Your charge nurse is being too hard on you. Perhaps because she knows she is partially at fault because she should have been keeping a closer eye on you. You're new and 12 weeks doesn't make you a labor nurse yet. She knows you still have lots of learning to do. There are a lot of things that can only be learned through time and experience.

When I was a new nurse (in the dark ages) I had a patient with an epidural that I pushed with for over 2 hours with very little progress. I was with her constantly. The doctor finally said to take her to the DR and he'd put on forceps. As I was wheeling her bed across the hall, she vomited and when we got to the delivery room and pulled back the sheet, the head was out. Her doctor scolded me and said I had to learn to watch my patients more closely. Some days you just can't win. But in that case, as in yours, no harm was done. And I learned how effective vomiting is for moving a baby's head down.

[CrazierThanYou]

I cannot believe the charge nurse told you that you should have crossed the patient's legs! Is she mad? Insane? Geeeez.

[bagladyrn, RN]

I'm still shaking my head over this "cross her legs" thing! What century is your charge nurse from?

I've been in OB for 22 years now and still don't own the crystal ball that tells me which pt. is going to precip! If the doc complains then he gets called to come in when all of his patients are 8 cm. (Then if he doesn't come in and misses the delivery I can say "I told you".)

Another factor here is that your patient was on Mag, I'm assuming for PIH. I've found that PIH'ers frequently go very fast once they get started, almost as if the body knows they need to get that baby out.

[cjohnsonrn]

I was pregnant with my first child and 30 years old. I went to the hospital, they checked me and said I was 3-4 cm with contractions every 4 minutes so they placed me in the room, started the IV and placed me on the monitor. They let me get up to go to the bathroom less than 30 minutes later and when I got back to the bed I told my husband I thought I had to push. He ran and got the nurse, who pushed me back on the bed and said she was crowning. She then asked if this was my first, and caught Ava. The nurse could not believe that this was my first pregnancy. I am an ER RN, and I couldn't have told you that I was going to have her right then. There was no way at that point I could have crossed my legs and not pushed. You are trained to deliver babies if you have to, and you sound like you did everything you could have. Some women have fast labors. At least I knew that going into my second pregnancy, and my OB induced me. I labored 4 hours with my son and pushed twice. I thank God I didn't have him at home. We have delivered too many babies in the ER and lobby lately. When that baby wants out they come. I wouldn't let the charge RN make you question yourself too much.

[RNLaborNurse4U]

Like the other posters said...don't kick yourself, or allow your charge nurse or attending MD to berate you. Teenagers (especially those who are preeclamptic) will either putz along and need a c/s, or will precip. IT HAPPENS. Don't beat yourself up about it. I've also found that if mom has a complete, involuntary urge to push/is actively pushing, just be prepared to catch.

[DCoffill, ASN, RN]

Thats just Silly!! I would just brush the talking to right off your shoulder! I was induced 2 years ago...i was 2 centimeters for 8 hours!!! i walked around for about 5 minutes got back in bed and asked for an epi and the dr checked me again and i had made it to 6...he said i could have the epi. Less then 2 minutes after he left the room...i felt the urge to push, my husband ran to get the nurse (who basically told him he was crazy and it wasnt possible) she came in lifted the sheet and told me to hold my legs together!!!!!the dr ran in got one glove on and my baby was born, LOL! I sat at 2 for hours, went to 6 in 5 minutes and baby was born 3 minutes later. I'd have to say if people got in trouble every time a baby was born out of normal situations...my nurse and Doc ought to be fired :) You sound like your doing a great job for 12 weeks out, good luck!