Precipitous Labor

One of my pts today, being induced for hx of precip. labor, went from 4 to delivered in 15 minutes. With no meds, not even local. I seriously walked out the door, got some meds for an epidural, went back in, and she was wild-eyed, writhing in the bed, saying the head was right there. My preceptor was at the desk, and I called for her to come right away. It was almost impossible to get the baby on the monitor; my preceptor was opening all the sterile stuff and trying to get to the bulb and clamp incase the doc didn't make it. My question is, what should have been my priority, since my sterile field was being set up for me? FHT tracing, or something else? And was it appropriate to turn off my pit? Considering the adrenaline, I think I remained calm pretty well, despite my hands shaking on the US trying to track the baby. The day will come when I am in that situation alone and I don't want to freeze.

Thanks for your input!

YOU DID GOOD!!!!! As an experienced nurse, I will try to help you out....

This will happen to you again....and again, bank on it. You sound like you did FINE---it's always nerve-wracking to have this happen to us........look at the things you did RIGHT and praise yourself. Look at what could have gone better, and remember it for next time.........

Meantime, these suggestions may help:

Review in your mind all the steps you need to take to handle precip. deliveries. Having proper equipment on hand/knowing exactly where it is is critical: Bulb syringe, clamps, scissors, warmer, oxygen/suction, plenty of towels/blankets for baby and KNOW YOUR NRP and STABLE training WELL.

These babies deliver themselves, really. It's a misnomer to say "we delivered them"-----but we do. Before the head delivers, have syringe to suction nares and mouth. Then feel for a nuchal cord and try to reduce if possible.....control delivery of head by putting gentle pressure (DO NOT PUSH AGAINST HEAD) on it as it emerges. Your object is for baby not to POP out, but to "ease out" if possible.......they often fly out anyhow, however. Just do your best....

The hardest tasks before you are to keep mom and s/o's calm during this stressful time---- and to ensure the stability of the neonate immediately after delivery.

Drill yourself or have others drill you the "what-if's" again and again. Experience is a great teacher. Being calm is paramount. Knowing NRP also paramount.

The pitocin was not your priority; turning it off was fine, if it was running low-dose, personally, I would have left it on.

Remember: If you don't have any pit handy or on IV drip, make sure it's drawn up for post-placenta delivery in case of bleeding that does not respond to breastfeeding or fundal massage.

You can inject pitocin IM if you have no IV access, remember. ALSO have methergine/hemabate handy, as well. Where I work, we have a "tackle" box with pitocin, suture (for dr), needles/syringes, cord clamp, etc ---easy to grab and it's all there. Do you have a "precip" pan? If not, you should. Or at least have a tech or nurse very ready and quick at getting the appropriate supplies for precip delivery. The above supplies will do you fine-----will get you by til dr gets there.

Remember, any time, a "precip" can present at your doors (happened to me twice last Friday!) BE PREPARED for whatever comes in the door. Know where your supplies are, know your NRP/STABLE and stay on your toes. Before long, "precips" won't be the huge worry they are now. You will be an "old hand" at it after a few years. Remember, these babies deliver themselves. All you have to do is remain calm, "catch" and ensure stability of mom and baby after delivery.

Don't be afraid to use the call-light button anytime you are faced w/such a situation again------if you need to, pull the light out of the wall, it will send an emergency signal to your coworkers to help you out!!!

GOOD LUCK and CONGRATULATIONS on a JOB WELL DONE!

Let's see now: in that short amount of time you had to rearrange the furniture in the room, and maybe the village of visitors, call the physician and maybe wait on the line until he/she answered, turn on the warmer, make sure the oxygen and suction equipment are present and functional, alert the baby catcher or whoever stabilizes in your unit, position the patient, break down the bed, get the water and blankets, calm the patient and the visitors. Don't forget they want BP's q 5 minutes in the second stage and maybe the patient was now upset and saying "but I didn't want to go natural." At any time, or at various times, if you got FHT's (it sounds like you had in external monitor on) I'd say you did good!

In my nearly 30 years at it, I'd say that babies that come that fast are usually just fine, except they might be a little shell-shocked for the first few minutes. When they come that fast, you can rule out a cephalo-pelvic disproportion or serious cord involvement. I'd suggest you talk about it with your preceptor and anybody else who might have stepped in to help; debrief a little and then pat yourself on the back.

DEFINATELY pat yourself on the back. I think you did admirably!

One of my pts today, being induced for hx of precip. labor, went from 4 to delivered in 15 minutes. With no meds, not even local. I seriously walked out the door, got some meds for an epidural, went back in, and she was wild-eyed, writhing in the bed, saying the head was right there. My preceptor was at the desk, and I called for her to come right away. It was almost impossible to get the baby on the monitor; my preceptor was opening all the sterile stuff and trying to get to the bulb and clamp incase the doc didn't make it. My question is, what should have been my priority, since my sterile field was being set up for me? FHT tracing, or something else? And how serious is it that I did not get a good tracing the last 5 min? (Apgars 8 and 9.) And was it appropriate to turn off my pit? Considering the adrenaline, I think I remained calm pretty well, despite my hands shaking on the US trying to track the baby. The day will come when I am in that situation alone and I don't want to freeze.

Thanks for your input!

First, always call for help. It sounds asif you did that appropriately. Any family member in the room can help you in this way. If the head is emerging, just support the perineum. If you have a few minutes, get a fetal heart (if it is not already tracing). If the head comes out, just support it while you check for a cord around the neck. By that time, someone will usually be there to assist you.

Always remember, if the baby comes flying out, it is usually fine and there is nothing you could have done about it anyway. Pit off is good because it should be off until the placenta delivers anyway. But that's not a big deal.

You got a great baby. You couldn't have done any better. Probably you were monitoring continuously as you had Pit running. Often, the tracing isn't good right at the end anyway. That's a reality. Don't worry about it.

You did fine. In situations like that, you just do the best you can.

By the way, as an aside, I would add that it is always good to have your set-up ready (and your baby stabilet as well) whenever you are doing a labor. A precipitous delivery is just the reason to be all ready. At my facility, we always keep a delivery table set and ready to go. In this type of situation, it's a blessing to be all ready. Today you had a good example of why you should be prepared. That way, preparation is one less thing you have to worry about the next time you are in a similar situation.

When I was in charge the other night, I had a lady come in and literally deliver within 5 minutes of rolling through the door. Because we had a table ready, all I had to do was ask for help and I caught the baby. By the time the doc got there (and she was only in the next building), all was done and we were waiting for the placenta. It was a great experience! Those are always an upper!!

Since I have a fantastic preceptor, she has taught me from Day One to always check EVERYTHING in your room the first thing (unless a pt is in there, and of course, assess the pt first!) so you know you're ready for whatever comes through the door. We have a "baby closet" in every room with stylets, ET tubes, laryngoscopes, suction catheters, bulbs, cord clamps . . . whatever you could possibly need. So we had 02 and sx for mom and baby ready, baby meds, a delivery table (though not set up - we can't leave our sterile fields up for more than an hour) with the doc's preference of gloves and sutures, so we really were ready; I was just not exactly prepared for all that mentally. Now that I look back on it, I think I did ok - I was trying to get her to breathe through everything and NOT to push, which I considered pretty important. I felt safe because my preceptor was with me and I knew she could deliver the baby; I've seen her do it before, and draw the cord blood and gasses too! I was worried about the baby being shocky because it had happened so fast, but by the time the baby was out all personnel were assembled in our room. The charge nurse was the baby nurse; another woman who I feel safe with in any situation at all. I'm just still so much trying to get the hang of everything that I must do in a delivery I felt like I was caught in the middle of a chinese firedrill. I believe you that "experience is the best teacher", and that after a while it will not phase me that much.

Thanks for all your responses!

I don't know about you all....but when I want a baby to deliver, I call for an epidural. Seems that just calling dilates that cervix and the baby comes flying out. The epidural effect one anesthesiologist calls it.

My rule of thumb is....when a patient is 4-5cms...I set up for delivery. You just never know. I hate being caught without stuff being handy, although, sometimes it just cannot be helped. Always be in the habit of checking your room when you first get there..make sure stuff is where it should be and WORKING.

I love precip deliveries, could do them all of the time.

Sounds like you had a great day, and an experience to put in the book. Look forward to many more.

I love precip deliveries.....I could do those all of the time.

We have a precip bag hanging on the back of every door w/what you need to catch a baby (bulb, blankets, clamps, scalpel, hat) and we try to always get the table set up when a mom hits 5cm.

Former OB nurse here. I think my first priority would be reassuring the mom, hit the call bell and get an assistant to call the doc, get equipment ready, etc. Stand down there in a catcher's position and tell her your best story of babies coming out fast are the most likely to be just fine and screaming. Tell Dad to help her breathe, and hold her hand, and just ease that kid on out.

We have a precip bag hanging on the back of every door w/what you need to catch a baby (bulb, blankets, clamps, scalpel, hat) and we try to always get the table set up when a mom hits 5cm.

I think this is really an excellent idea. We just have precip "pans" ourselves. they can be grabbed in a flash, but this idea is really great. will have to discuss it w/manager and coworkers.

Sounds like you did great. Everyone has given you great advice on how to deal with a precip. The only thing I'd like to add is to keep reassuring the mother. It is very frightening for most women when things are going that quickly, it's overwhelming. A continuously murmured mantra of, "You're fine. Everything is going exactly how it's supposed to. You're doing great. Take a breath, that's it, perfect." or words to that effect. I often find that getting close to the mom's head and whispering in her ear is most effective when there's lots of noise and fuss in the room.

Back when the world was young and the ages dark and I was a new nurse, we used to have women pant to not push. I don't d/o that anymore. When they push, I just tell them to take a breath; every time I see/hear her start to push, I tell her to take another breath. There's a little pushing going on, but not much, and they don't hyperventilate like they used to.

As far as getting fetal hearts to record, good luck. With the baby way down in the pelvis and mom thrashing about and being vocal, it's not unusual to not be able to find it. You keep looking, because if they're down very low, you'll want to let her push it out sooner rather than later, but if they've been good, you don't really have much to worry about. Just document that you were hand holding the monitor and searching; or however your preceptor wants you to word it.