Jiayou

MIchelle L. Murray's " Labor and Delivery Nursing A guide to Evidence- Based Practice" is a very good book for new grad. It is my third year in L&D, I still look it up frequently when I have questions . It is very helpful.

Good Luck Klone!

Sorry I didn't realize there is a big gap between manufacturer recommendations and actual practices in hospitals. We don't use the second dose of cervidil in our hospital if the first dose fails. We use IV pitocin 30 minutes later after removing the cervidil. I think the book provides me the evidence of practice when it says "No" to the question, " Can more than one dose of Cervidil lady partsl Insert be administered if inadequate ripening occur?" and give the explanation of manufacturer's recommendation.

No. Cervidil can't be repeated. According to my book "Intrapartum Management Modeles,"The manufacturer does not currently recommended more than one application of the cervidil because adequate studies have not been conducted on repeat dosing" (pg 226)

Hello everyone, I finally found the evidence! In the AWHONH book, in the chapter, " Guideline for the Management of pts with Diagnosed or suspected placenta previa during the peripartum period," it says "Beta - agonist (Ritodrine, Terbutaline) are contraindicated in the presence of active bleeding" ( "High-risk & critical care Intrapartum Nursing" written by Lisa K. Mandeville and NAn H. Troiano, pg 428).

Thank you all for your posts. They are very informative. I appreciate that. Especially thank you cnm in progress and Klone for your opinions from different points of view. I have learned a lot. I will consider more the risk vs. benefit next time when I make my decisions. Thanks.

You can work asa CNA in postpartum or try OB tech in Labor and Delivery

Hello, Will you give terbutaline to lady partsl bleeding pt? One of my pts was G4P2, 34 weeks GA, had intermittent lady partsl bleeding. Ultrasound showed that she had placenta previa. Because she had contractions q 3 minutes, MD ordered Terbutaline 0.25 mg sq. Before I gave the terbutaline, one of my coworkers remind me that Terbutaline is contraindicated in lady partsl bleeding pt. I realized that because one of side effects of Terbutaline is Tachycardia, Terbutaline might mimic the s/s of active bleeding. I then held the Terbutaline and called the MD again. He ordered to not give at that time, but later he still blamed me for not giving pt at least one dose. I tried to find any document which can prove that Terb is contraindicated in lady partsl bleeding pt, but no findings. I am wondering if you know anything about that. What will you do in that kind of situations? Thanks.

Thank you everybody for your understanding and encouragement. Your warm words really infused in lots of strength to me. I really appreciate that. No, I don't have choice to switch to the night shift even though I am suffering or torturing in day shifts. I already talked to my supervisor. Because I am new, I have to work on the days they assigned me. I tried to read more books, take more classes, and study more to make up my knowledge deficit problem, but I really don't have any idea how to survive in that environment. Thank you everyone again for your support.

Hello, It is a terrible experience, and I feel so shameful to share, but I really need some advice to help me out of this deep dark hole ---I am so lost in L&D. I didn't have any confidence now...I don't know if it is my problem - am I too stupid or - the environment just not good for me.... Although it was very tough and challenging, I have survived in L&D for 6 months, including 10 weeks orientation. I used to take care of two pts in the night shift, no matter how hard or easy my pts were. I gradually built up my confidence. However, after one day, I lost all my confidence. I feel my knowledge and ability are still in the orientation level. I am totally lost - I doubt my ability, judgment, and knowledge... I delivered a baby without doctor's presence today. Mother and baby's outcome were good. Apgar score 8-9, Perineum one degree laceration, and the pt and her family appreciated my help and said I was a great nurse. However, it did prove my poor judgment - I missed the best time to call the doctor, especially when the pt was G1P0 and on Epidural. I know it was unforgivable, especially in doctor's eyes, but I did try my best. The baby's water bag was so hard and big that I could not evaluate the fetus's station accurately (I am a new grad, but I thought it is not our scope of practice to break the water bag. Even if I could, it was very hard to break, which was proved after I delivered the bag). The pt's contraction was not strong, and she refused to push because she c/o back pain (she had already labored down for one hour) . I spent most of time encouraging her, changing her position so she could try to push without hurt her back. When I noticed that I could see the quarter size of water bag, I realized that I need to call the MD. However, the pt's contraction suddenly changed to very strong and effective. She pushed the water bag and baby's head all the way out ! (She was on epidural,but she couldn't control her push at that time - can anybody believe that?) I didn't have time to think, the only thing I could do was to break the bag, and tried to pull the baby out, and at the same time, let family to go outside to ask for help! My coworker helped me to finish the rest part. The doctor arrived two minutes later after the baby out... He was very mad at me...He did not remember that I already notified him half an hour earlier that pt had pushed for more than 30 minutes, and push not effective, water bag bulging, and fetus's head low.... I felt like I was totally an idiot - what poor judgment I had! I should have called him earlier. Why didn't I ???? You might be wondering why I didn't call my charge nurse earlier. That is another story. I was scheduled to work in the day shift for couple of weeks. The charge nurse treated me like I was a totally idiot, no help or support I can get from her . I never could find her when I need her the most! When she was around me, all she did was blaming me all things I had done (when I was in night shift, none of my night charge nurses blamed me). I was very stressful when she was around. I already notified her that my pt was complete and pushing, but she never showed up in my pt's room, nor assigned an OB tech with me. When I pressed the call light, nobody answered me, so I asked family to go outside to get help.... I was scared and frustrated. I had talked to my manager before about the issue, but she said that I am not competent and too dependant. She said that the charge nurse c/o that I could not take two pts at the same time. The fact is I always took two pts at night shift, and the days I could not take 2 pts were that I had difficult pts. Once she assigned me the drug abused pt who cried all the time and was in active labor - pt delivered in two hours from the time she came to the hospital); another time she wanted to assigned me a new admission who was already 6-7cm dilation when I already had an active labor pt ( cervix dilated 5-6cm, first baby, on cervidil, and had recurrent deceleration - because the MD refused to take the cervidil at the beginning, I had to contact him again and again - After the delivery, pt had PP hemorrhage!) The charge nurse was very, very angry when she realized that she could not assign me the second pt. She said that I don't know how to prioritize, not competent, not ready to be a L&D nurse, and she would write me up... I know I am not good enough. I am still new and I am still learning. She is right. I am still slow and not effective as those experienced nurse. But am I really bad as a 6 month new L&D nurse? I never believed her. I trusted myself before today. But after today, I realize that maybe I am not smart... My self confidence was severely impaired by today's incidence and charge nurse and manager's attitude. I began to doubt myself. I could not make a good decision the rest of the day. I even could not give a complete SBAR report. What can I do? How can I survive in this kind of situation? I am also worried that maybe our director will fire me because I am so bad... I am very sorry the story is too long. However, I will really appreciate it if you can give me some guide.

Thank you all for your wonderful posts. I appreciate that, especially thank you Christine for your web site. I learned a lot. Thanks.

Thank you very much babyktchr ! I really appreciate your information.

Hello, I had a drug abuse pt whose drug screen result shows that she is positive in Amphetamines, Metamphetamine, Methadone, and THC last night. She screamed for UC pain all the time. The doctor refused to give her Stadol because he said it was contraindicated in drug abuse pt. I am wondering if it is true. If it is true, how can you deal with pain for those kinds of pt when epidural anethesia are not available? Thanks.

I agree with bagladyrn. In our hospital, we will give hemabate too instead of methergine. I don't know lomotil can be used for diarrhea. Thank you bagladyrn.

Thank you so much SmilingBluEyes. It makes sense to me now. I really appreciate your explanations. Now I think I know how I can deal with those irritability. Go back to my original question, can you please tell me how you will identify uterine irritability from contractions (especially hyperstimulation)? Thanks.

Dear NurseNora, Don't feel sorry. I really appreciate that you tried to explain those relationships to me. Thanks a lot!

Thank you so much NurseNora for your information. I really appreciate that. Actually the pt was on IV. When I saw those irritability, I gave her some IV bolus, and assist her to the bathroom frequently, but she still had those HFLA. I didn't know that lying on her back would also cause irritability. Why lying on her back will cause irritability? can you please explain more to me? Thanks.

Hello, I am wondering if somebody can answer my stupid question. I know it is a basic question, but I just can't find the answer from my OB reference books. When I took care of my G1P0, GA 34 weeks pt last shift, I had an order to give Terbutaline if pt had contractions. However, I couldn't see any typical bell shaped contractions in EFM. Instead, I saw some irregular, low amplitude, high frequency waves. I palpated the abdomen, I could feel the uterus tightening during some of higher amplitudes waves. I am wondering how you identify uterine contractions from irritability. If preterm labor pt only has uterine irritability, and no obvious contraction (No cervix change), will you give Terbutaline? Thanks

thank you so much rnlabornurse4u for your explanations. they really make sense to me. i appreciate that.

Thank you Feisty for your response. I appreciate that. It is very interesting to hear that making judgment based on mean arterial pressure. Do you have any evidence based research? Because it is my first time hearing that, I am eager to learning more... Thanks.

Thank you SmilingBluEyes for your response. I appreciate that. Do you mean we still need to pay attention to hypotension caused by lateral position? If patient has low BP in one side, we need to turn to other side to get optimal placenta perfusion? Will the BP be different when putting pt in different sides? I though they are the same. Maybe next time I will put patients in different sides to check if there are any differences.

Hello, I am not sure if any of you encountered such a problem, but I was bothered by this question for a while. When I turn my patients to lateral position, most of them will develop hypotension. I am wondering if we need to do some intervention for that or just leave it alone. For example, my patient last night had BP 121/69. When the tracing showed that she had two variable decelerations, I turned her to left lateral position right away. A few minutes later, her BP dropped to 92/45. I was really confused what I supposed to do. One of my experienced coworkers had told me that because the hypotension was caused by the lateral position, we don't need to do anything. However, hypotension will also cause uteroplacenta insufficiency, right? Do I need to turn patient back to normal semi-Fowler's position in order to get BP back to normal or just leave it alone? Any idea will be appreciated.

Thank you butterball1980 for bringing up this question. I happened to have the same question as yours. When I read some books, I did see tracing of fetal heart rate, whereas the book ended up saying it was a still birth. I was curious too. How can I identify if the fetus is still alive or dead if I can still see FHR 140? Just absent variability? I'll really appreciate it if you can find the answer and update us.

Thank you all for your comments. I really appreciate that. I found the original statements about "doubling" contractions in my books. In Michelle Murray's " Antepartal and Intrapartal fetal monitoring," it says," Action in response to doubling include discontinuing the oxytocin infusion and evaluating the pelvis and fetal position and size for fit (Pg 45)". It says, " If the fetus is not in malposition, and the pelvis is found to be adequate for the fetus to descend and deliver lady partslly, and oxytocin was infusing, and the FHR pattern demonstrated fetal well being, the oxytocin infusing could be continued in order to establish a normal UA pattern. If the fetus has decelerations and oxytocin ordered to continue, the physician should be readily available to handle complications." In my "EFM Case Book" from CCPR, in a case with a coupling contraction , the rationale says, "...coupling ...may suggest a hypotonic pattern or occur after administration of medication. In this case, plotting a labor curve could help the nurse assess the progress of labor. If this woman's cervix is dilating less than 1.2 cm per hour during this active phase, a protraction disorder may be diagnosed and augmentation initiated." My understanding is when we find "coupling" or "doubling" contractions, we need to assess pelvis status first. If the pelvis is adequate for NSVD, FHR is reassuring, and contraction is not adequate for cervix to dilate, we add more pitocin (if there is order for pitocin). What do you think? Thanks.

Hello, I have questions regarding to "coupling" or "doubling" contractions. One of my patients whom I took care of two weeks ago had "doubling" contractions every 3 minutes and she was already on pitocin 2 mu/min. I was hesitate to add pitocin to her when I found that she had "doubling" contractions . I consulted with one of my experienced co-workers, she said it was ok to add more units pitocin. I then added one more unit. The pt delivered two hours later with good outcome. However, when I read books when I got home, I noticed one of books said that most "doubling" contractions caused by persistent OP or OT position, and pitocin need to be discontinued; Whereas in another book, it says "coupling can be normal or may suggest a hypotonic pattern", and then the book suggests to initiate agmentation. I am wondering which statement is correct, and what you will do if your patients have "doubling" contraction? Thanks.