obnoxious OB

Whoa! Was the GBS status even confirmed? I hope she was negative. And why did he want to break her water so early in the AM? Can't you have him written up for not following protocol? I mean, there wasn't an IV site, and what if there was, and it wasn't patent? Don't you think he'd want to check this out before? OMG- what a nightmare! Kudos to you!

oh, yes I forgot to mention that I believe the pt was GBS positive!

Which the OB must have known, but I didn't know at the time because I hadn't even put in her history yet!

What a disaster.

I mean it was her first baby, so most likely she didn't deliver for several hours.

But it was still stupid of him.

For many reasons.

Take a moment and give yourself a break. You did the best you could with the resources and experience you had. Yes, this patient should have had an IV before AROM. In the future, I might approach it like this, "Dr. Doe, the patient has just arrived and I will be happy to assist you with AROM once her IV is established." Period, end of discussion. One of the most difficult things for new nurses is learning to effectively and passionately advocate for their patients. This is even difficult for experienced nurses. I'd like to give you an example, if I may.

I was charge nurse in a L&D unit a couple of years ago. One of the nurses was taking care of a 38 week fetal demise. I knew the MD had started pushing the patient and this particular MD didn't have the best reputation among his nursing and medical colleagues. He would often push patients who were 8 cm and he also extensively manipulated the perineum as a matter of course.

Anyway, the nurse caring for the patient came out of the room to get forceps and the residents. I immediately questioned this since this was a fetal demise and they had only just started pushing. I knew the MD was looking at this birth as a teaching opportunity on how to use forceps since there was no risk to the baby. Make sense? So, I asked the MD to come into the hall for a "time out." I told him that I was "concerned" about his decision to use forceps on this patient since both the patient and infant were not in any distress. He gave me a long story about how good he is at using forceps and asked for my support. I told him that I would not support him, but at the time, I just didn't have the experience or guts to take the issue further. He delivered the infant with forceps and, to my knowledge, there were no repercussions.

However, I ask you to consider a few things I learned from the situation. One, forceps can cause cervical and lady partsl lacerations that can lead to a infection in the postpartum period. Is it worth the risk? A cervical lac can lead to an incompetent cervix in future pregnancies. Is it worth the risk? We should always ask ourselves these questions when we care for our patients. Many of our interventions have a degree of risk involved which is unavoidable. However, the benefit MUST outweigh the risk or we are being negligent in the care of our vulnerable patients who unknowingly assume that we always have their best interests in mind. In this case, this MD did not. Did the benefit of AROM with this patient outweigh the risk? Definitely not.

After thinking long and hard about this birth, a few things came to mind. We had no idea how long that infant had been dead. Her skin could have very well been extremely friable and using forceps on her head could have easily caused unneeded damage. Additionally, we neglected the emotional aspects of this patients care because we further traumatized what was already one of the most difficult days of her life. Last, this was a life-altering experience for me. I decided on that day that I would always consider my patients from the following point-of-view. If she had been my daughter or loved one, having the knowledge that I do as a healthcare provider, would I allow the intervention in question to be performed? I know good and well that I would have never allowed that MD to use forceps on my daughter under similar circumstances. Everyone deserves the same level of care that you'd want for yourself and your loved ones. Would you have allowed the doc to break your water without a IV in place? Of course not, because you'd want to have IV access in case you had to run to the OR with a cord prolapse.

OP, I'm not judging you in the least and I have actually had the exact same thing happen to me early in my career as an L&D nurse. I made the same decision you did and was bullied into it. It won't happen to me again though, I assure you. I am only trying to help you with examples of how you might respond differently in the future. In the future my actions will bee different as I know yours will as well. I would have told the MD in the example above that I was not going to support forceps use and that we would either have to wait for her to labor down a bit or involve the powers that be. I know that much worse things happen in healthcare but the truth is that every little thing matters. I make it my business to ensure that not one little hair on each of my patients head is unnecessarily harmed if I can prevent it.

Thank you for sharing your story. You are not alone and sadly, we all have to learn these lessons. Be strong and know that we are here to support you through the good and bad. No matter what! Tabitha

I encourage my staff to write that stuff up and it gets sent to peer review. The worst thing to hear is "he always does that". That doesn't make it right. I know it is difficult to stand up to the mighty MD, but you know what.....would he be there for you in court supporting you if something did go wrong?? That isn't even what is most important....what is best for the patient?? The patient gets lost in this tug of war and that is why we all are here anyway...for them. Best practice is to take the BEST care of the patient.

It's ok what happened. I am still a very new L&D nurse - been doing it over a year now. But there are still moments with doctors, co-workers and PTs where I stop and kick myself and think "next time I will handle that differently". That is how we learn. Its not until you have those situations that catch you off guard where you figure it out. You learn where you draw your lines in the sand, you learn what battles you fight and ones you don't, you learn that you do have the "balls" to a doctor and tell him politely to leave your PT alone until you think the time is appropriate for whatever the intervention is.

It is hard to say no, especially when someone who others say is more powerful is bullying you. I can remember more times than I care to admit this type of thing happening to me when I was a new nurse. But always remind yourself when you are in this situation, YOU DO NOT WORK FOR THE DOCTOR!! No matter what they may think! The hospital employs you to take care of patients, not doctors. I always tell my students to look at a situation and make sure you are acting in the patients best interest before you proceed, for both moral, and unfortunately in todays world, legal reasons too! You sound like you are doing fine, and remember you are not alone. Stay strong! :)

We all make mistakes, don't be so hard on yourself. Next time you'll know how to handle this situation. Next time tell him I need to start an IV first, ignore him as best you can. If you're new on the unit you will not be able to avoid working with this OB, because all the other nurses who have been there longer than you are trying to avoid him as well, and they're going to dump him on you. Most OBs are this way pushy nasty rude, ignore him when he sees he can't frazzle you he'll cut it out. At times you will have to give him a little of his own medicine. Reporting a doctor from my experience goes no where, they bring in the patients (money) managers are always going to tip toe around them, yet a nurse is always disposable for hospitals.