anitame

I was taking care of a patient who had a lady partsl delivery with a 3rd degree laceration. The physician was doing a rectal exam to check for sphincter involvement. I had told the patient to take deep breaths, that it might be uncomfortable for a few minutes. She kind of giggled and said "Actually it tickles." The look on her husband's face was indescribable and the physician and I couldn't help but laugh. :)

We always have 2 RNs for lady partsl deliveries as per the NRP guidelines. The 2nd RN stays until things are stable and the primary RN is able to assume care of both mom and babe. For C/S the OR crew is there for mom and one of the LDRP nurses and the ped are there for the baby.

It can be more difficult to detect the contractions with heavier patients but it's not impossible. You just need to find the best spot; sometimes this takes some time. Then you need to reposition the toco after position changes, etc. Unless the patient is on Pitocin or has less than ideal fetal heart tones, I don't stress too much about the toco.

Wow sheRN, this sounds like a horrible setup for the employees and great for the hospital. Your hospital must not be union? At my hospital the situation you described would NEVER fly. Our census has been ridiculously high now for over a year, but even when it was low we were given the OPTION to stay home, usually on call. Someone was always happy for an unplanned day off and we can use our accrued time off for compensation. The one time I actually was asked if I wanted to stay home that I chose to work, it was no big deal. Another nurse was glad to have the day off. I think I'd be looking into changing employers if I were you. This place does not sound like a good place to work IMHO.

Thank you Bonnie for sharing your story :) It takes a lot of courage to discuss something as serious with this. I think it's WONDERFUL that you're educating and helping people. :) And reminding people that it's a disease and there is treatment. Anita

Wow!! Congrats!!!!!! and have fun.

I'm sorry to hear this Louise. It's got to be hard being on bedrest and worried sick with 3 little ones. Well, at 22 weeks you're definitely too early to deliver and there is a wide variation in what happens with previas. Some patients remain on bedrest until term and then deliver a healthy baby via c-section. Others are hospitalized several times for bleeding and have their baby early via c-section. Your best bet is to be vigilant about remaining on strict bedrest; no easy feat with 3 other children, but it is VITAL at this time. If it appears you will have to deliver preterm, your caregiver might choose to give you IM steroids to help speed the development of the baby's lungs. Get lots of help lined up at home. And go to bed :) Good luck, Anita

Very well said Haze. I couldn't agree more. Anita

We were talking about this at work recently. The nurses who have been involved call it "splash and slash" c-sections. Apparently it happens every 4-5 years around here. I've never seen it and it doesn't sound pretty. The nurses that have seen it said that the moms seemed to tolerate it remarkably well, maybe due to the massive adrenaline rush/fear???? It will be interesting to hear from others who have actually been around one.

We almost always use Fentanyl as a first choice drug for pain meds, it's a standing order on our labor order sheet. Even if they have planned an epidural, they often get the Fentanyl while waiting. We have around a 30% epidural rate, the rest mostly use Fentanyl with the occasional nonmedicated labor. We use 50mcg over 2 contractions. May be repeated in 10 minutes, not to exceed 100mcg q 1 hour. We will sometimes give the 50, wait the 10 min, then give the other 50; sometimes we give 50 q 30 min. Depends on the patient, the labor, etc. I have started using the 100mcg dose more often, it tends to give a little better relief. There are several things about Fentanyl that are great. One is that is has a very short half-life and we see VERY few sedated babies. The other thing is that there is no limit to the dosing. I've heard with either Nubain or Stadol (can't remember which) you can only give a couple doses.

Lots of good points. I always change needles too. My four year old had to have blood work, we used the EMLA and she watched the whole thing. Didn't even flinch. The lab tech was absolutely blown away. Said he'd NEVER had a child that young just watch.

A very smart and well respected CNM I work with recently gave me this tip. I tried it with my last two injections and it seemed to work. From the time you inject the needle until you remove it, use the tip of the index finger on your dominant hand to scratch the patient's skin directly beside the injection site. Apparently it "confuses" the nerve endings to feel the scratching (which probably actually feels like rubbing with gloves on) instead of the pain from the injection. I did this the other day to a woman receiving her second Betamethasone injection (painful). She said she couldn't believe how different it felt from her first shot. Said she kept thinking "I hope you don't stop scratching that spot" She said she was amazed at the difference in the pain level from the injection the previous day. Made a believer out of me! Definitely can't hurt, worth a try. Best of luck to you and your wife. Anita

This was discussed recently on a perinatal list I subscribe to. The general consensus is that the the insert that comes with the ISEs will list the manufacterers recommendations. Most indicate they should not be used in the presence of GBS. That said, if I have a baby with an icky looking strip, I would certainly prefer to use an ISE and confirm fetal well-being than go for a c-section. We do not discriminate with the use of ISEs in GBS positive patients but we don't routinely use the ISE either. Only when necessary. Normally the docs/cnms will not AROM until after the second dose of antibiotics so USUALLY these patients are well covered before they would even get their ISE. Always exceptions to the rule though!

RN's don't AROM in Oregon either.

I vaguely remember learning at a wound care conference years ago about Bag Balm. If my memory serves me right, since it's manufactured as a vetrinary product, it is not held up to the standard of a medication during production. The FDA has no control over quality controls, etc. And I believe one of the ingredients either is or breaks down to a antibiotic/antimicrobial agent, which caused the speaker at this conference to be concerned about unnecessarily using antibiotics on wounds. This has been a while, so maybe the thinking on this subject has changed? I definitely would not use it on my nipples while breastfeeding after hearing the above information. The ONLY thing that should be used routinely on nipples is Lansinoh, which is 100% Lanolin. It would be interesting to hear from the wound care nurses about the Bag Balm, I haven't done wound care for about 2 years. Anita

We don't really have a set time for a C-Section in this scenario. Usually we will start IV antibiotics after a certain length of time (12-24hrs depending on the providor). We also keep lady partsl exams to a minimum. If the patient is making progress we will usually just let her go. Sometimes it takes longer than 24 hours, if the mom and baby are both doing well we tend to be conservative. We have a staff composed of certified nurse midwives (conservative approach) and newer OBs who believe in decreasing the primary C-Section rate. We had a patient about a year ago whose membranes ruptured and she came in. Her OB was off and the on call wanted to start Pitocin. She refused until her OB was back. We just put her on antibiotics and waited. She finally was started on Pitocin after almost 48 hours and delivered lady partslly without complications.

All this has made me very grateful we do LDRP/couplet care! We take care of our delivered couplets for the remainder of the shift unless we're short on L & D staff and doing the revolving door thing.

EMLA works great! I put it on my daughter before a blood draw and she watched the whole thing. Didn't even flinch, not bad for barely four years old. The lab tech said EVERY kid should use it, he'd never seen anyone use it before. Maybe this would help, in conjunction with the desensitization thing.

We have a list of things our unit has designated as high risk including use of Pitocin, epidural, NRHFR, no PNC and a multitude of others I can't seem to dig out of my head tonight. All of our epidural patients remain on continuous monitoring.

Nurses do it at my hospital. Hmmmmm, that sounded funny, huh? LOL The oral route sure would be nice, we still using only lady partsl. Anita

I haven't seen Prepidil used in a few years but we do have one midwife who uses Cervidil regularly. Usually is placed in the evening and Pitocin started in the AM if the Bishop's score is at least 7. She usually uses it for postdate patients. Most of our other providers are using Cytotec. The Cervidil seems to be a little gentler as far as the ripening goes but it does take longer. The only real complaint I have heard from patients about the Cervidil is that is causes some lady partsl irritation. Some women have a little more discomfort with vag exams, occasionally someone will c/o lady partsl burning. The nice thing is that it can be removed for hyperstim/SROM/labor. It's rare but I did have to do it once. Anita

I just thought of something else that might help during the night. A baby monitor with the base in the patient's room. I can hear my 2 year old breathing, it would be very easy to hear if she was getting up. The receivers have the ability to be run by batteries. I've seen them with 2 receivers too, one could be at the nurses station for those RARE moments at night when anyone's there! And the other could be clipped onto a lucky! someone's belt. Again, good luck Anita

Well, I don't know if this will help but when I worked long term care we had a few patients similar to this. One of our maintenence guys rigged up a laser light alarm. It's been a while so I can't remember what they're called but the nice thing is they're NOT restraints. We would set one up so the light beam was parallel to the bed. When the light beam was broken by patient (or staff!) walking through the light, an alarm would sound. Actually, it sounded like a doorbell. Much more pleasant than some of our other alarms. There was a choice of 2 tones and it could also be turned off while the patient was being assisted by staff. I don't know if you've tried something like this, but it really saved our butts when state came. It was one more intervention for the high risk for falls care plan and it really did work for some people. Also, it would free up your staff some at night! I hope this helps. Let me know if you want more info and I can contact the facility and see if I can get the name. Good Luck! I know it's frustrating! Anita