Nurse initiated SVE

Lisa CCU RN, RN · Mar 9, 2007

Wow. I don't know what to tell you but I'd be most upset about the fact the doc lied on me.

Good Luck.

dawngloves, BSN, RN · Mar 9, 2007

All theses cases, it's the same OB??? Yikes! Wish I could help you. Have you perused the AWOHN site yet?

**canoehead, BSN, RN** · Mar 9, 2007

The same FP doc working the ER (even worse). SVE's are so commonplace in OB that it's hard to find an article that specifically says what I need it to. It's like finding an article that says the nurse should be allowed to take a BP if someone is dizzy, without waiting for an order.

dawngloves, BSN, RN · Mar 9, 2007

Maybe you can just bring an OB Nursing text in and prove that it's "textbook nursing" to do SVEs.

SmilingBluEyes · Mar 9, 2007

I would bring this issue to the manager and the chief of staff, were it me. This person sounds dangerous.

**canoehead, BSN, RN** · Mar 9, 2007

The manager is already involved, as I said, the doc has initiated the discussion requesting we (I'm the only one who has the training) not be able to do an SVE. The head doc in the ER agrees with me but is not inclined to interfere. Same problem when she didn't want IV's started, he doesn't have a problem with nurses starting IV's if they feel it's warranted, but didn't want to interfere with what she wanted on the days she was on.

SmilingBluEyes · Mar 9, 2007

What a pickle. I am sorry I have no real solutions then.

**canoehead, BSN, RN** · Mar 9, 2007

OK, one question...frequently when I worked med surg we would get an order from a doc "don't take another BP until 6am" just so he could get us to stop calling him. Totally against the patients' best interests. We'd ignore it, obviously and expected and got our manager's support. I think this is a similar situation...the Board says I can do the exam if I have the training, no order needed. So if the doc says not to do it I would still be negligent if I didn't do it...and could be held responsible.

For example, someone comes in contracting, I wait for the doc to do the exam and there is a prolapsed cord. If I had done the exam immediately we might possibly have saved the baby. If I don't do it I feel responsible because I haven't stood up for my patient.

Please give me your comments, because even if there is no solution I will be better prepared for the meeting if I can get differing opinions.

NPinWCH · Mar 9, 2007

I work OB in a small rural hospital We always do our assessments BEFORE even contacting the doc. It's our judgement and may include: Spec exam, fern, FFN, u/a, GenProbe for GC/Chlamydia, wet prep, and SVE.

I know it's different in ER. Late last year the ER called and said they had an 18 weeker (we don't get them til 20wks) with lady partsl pain and discharge in triage, "We're swamped can you guys take care of her and then call us?" I said I could since we weren't busy. I got FHTs, and obtained GenProbe, Wet Prep and a U/A.

Tests came back: Wet prep negative, BUT Trich swimming in her urine. I called down to the ER, spoke the the charge nurse and got this reply, "YOU DID WHAT? ONLY THE DOC CAN DO THAT. YOU DIDN'T EVEN HAVE ORDERS FOR THAT!!!" She put the doc on the phone who then also yelled at me and said, "I don't care what those tests say, I'm just going to have to do them all over again. You weren't allowed to do that." I told him to forget it, cancelled her ER admission and changed her over to an OB clinic pt, then I called the OB on call, who is very nice and honestly didn't mind giving me orders for her meds, follow up and discharge.

Up until last year, an RN had to go on all OB transfers. I always checked my patient prior to leaving, even if a doc had just done it. I once received a transfer from an ER of a hospital without OB and the report I got was, "Her water is broken and the ER doc has checked her 4 times and she's complete." I said, "What? you can't send her if she's complete." The doc got on the phone, "She IS complete, but she's not feeling any pressure, so I'm sure it's fine." The receiving doc didn't believe it, neither did I. She arrived 40 minutes later sitting strait up on the cot, talking on a cell phone saying, "Oh no the doctor said I'll be having my baby really soon, I just need to start pushing." She was 1-2 cm, 20%, high and posterior.

RNfaster · Mar 9, 2007

i wonder if the following might help you. i am preparing to apply for nursing school (in my last prereq).

http://www.greenjournal.org/cgi/content/abstract/92/3/384

methods used to diagnose premature rupture of membranes: a national survey of 812 obstetric nurses - jl atterbury, lj groome, and c hoff

... conclusion: a sterile speculum examination is used more often to obtain lady partsl fluids for testing and to diagnose ruptured membranes in teaching or military facilities and when nursing personnel have been trained in speculum examinations.

http://www.merck.com/mmpe/sec18/ch260/ch260d.html

if labor is active and the pregnancy is at term, a labor-and-delivery nurse or a physician examines the lady parts with 2 fingers of a gloved hand to evaluate progress of labor. if bleeding (particularly if heavy) is present, the examination is delayed until placental location is confirmed by ultrasonography. if bleeding results from placenta previa, lady partsl examination can initiate severe hemorrhage. if labor is not active but membranes are ruptured, a speculum examination is done initially to document cervical dilation and effacement and to estimate station (location of the presenting part); however, digital examinations are delayed until the active phase of labor or problems (eg, decreased fetal heart sounds) occur. if the membranes have ruptured, any fetal meconium (producing greenish-brown discoloration) should be noted because it may be a sign of fetal stress. if labor is preterm (

http://uscnurse.usc.edu/class/579/files/laborevaluation.ppt#269,8,initial assessment - usc nursing program presentation on labor and delivery

http://mombaby.org/pdf/obalg_pretermlabor1.pdf

unc footnoted flow sheet that instructs on when to conduct sve/sse.

http://www.marchofdimes.com/prematurity/pretermlaborassessment.pdf

if unable to assess cervical status, do sve if ordered, unless contraindicated (i.e., lady partsl bleeding, preterm prom, vulvar herpes lesions). it is important to have the same individual perform sve’s, if possible, for the most accurate assessment of cervical change.

http://www.uab.edu/obgyn/web_handbook.doc

preterm premature rupture of membranes: diagnosis and management

american family physician, feb 15, 2006 by tanya m. medina, d. ashley hill

http://www.aafp.org/afp/20060215/659.html - six page article - excerpt:

the physician (note that the magazine is directed at physicians) should perform a speculum examination to evaluate if any cervical dilation and effacement are present. when preterm prom is suspected, it is important to avoid performing a digital cervical examination; such examinations have been shown to increase morbidity and mortality.14,15 digital cervical examinations also cause an average nine-day decrease in the latent period.16 shortening of the latent period may lead to increased infectious morbidity and sequelae from preterm labor. some physicians are concerned that not performing a digital examination may lead to the misdiagnosis of advanced preterm labor with imminent delivery, which has important implications for patients who require transfer to a tertiary care center; however, a prospective comparison17 found that the difference between digital and speculum examinations was not clinically significant. physicians should be reassured that careful visual inspection via a speculum examination is the safest method for determining whether dil-ation has occurred after preterm prom.

...

preterm premature rupture of membranes is the rupture of membranes during pregnancy before 37 weeks' gestation. it occurs in 3 percent of pregnancies and is the cause of approximately one third of preterm deliveries. it can lead to significant perinatal morbidity, including respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse, placental abruption, and fetal death. appropriate evaluation and management are important for improving neonatal outcomes. speculum examination to determine cervical dilation is preferred because digital examination is associated with a decreased latent period and with the potential for adverse sequelae. ...

MemphisOBRNC, BSN, RN · Mar 11, 2007

You need to take a look at the EMTALA policy for your hospital and see if RNs are considered QMP (Qualified Medical Personel). If so, that should be all you need to prove your point. I will also so some research and let you know if I come up with anything. Good luck. You did the right thing!