acuteobrn

Gwenith, Thanks for the referral! I checked out the site, doesn't have anything on what we are currently working on but the models are a good reference. I went to a conference last week, and it has shown that Euro/Australian medicine is WAY ahead of us on this one. Thanks again Acute

Ok, so I have been away from the forums, for quite along time, but I need some input. I am part of the hospital's EBP program and we are starting one for labor and delivery, my specialty. Now up till now, there is very little EBP used in L&D units as far as I can see. Especially at mine. We are trying to streamline out practice and have set standards, so that we can avoid having to use the chain of command on some of our older OBs. Are any of you currently using this type of pactice at your facility? I am specifically working on PPH and would love any input. My eyes are going cross with the amount of research out there and would like to know what other hospitals are doing, if anything. LIke I said, this is brand new to us, and is in it's embroynic stage at our facility. Any help, input is welcome. Thanks! BTW, I didn't realize how much I missed reading the forums! Acute

very interesting use of Torodol. I would be interested to know which conference you went to and their references.

I work at an institution where this is a standard option for 2nd trimester IUFD inductions. It works very well as another poster mentioned above, the POC and placenta were delivered sometime during the second bag. This is a viable option for those w/o CI. We tend to run standard AMOL on s/p c/s patients, dependant on their incision type and dating. I realise that when this is not your standard of practice it can be intimidating to use, however, if you were to research this, you will find that this is actually a safe alternative to several days worth of prosteglandins and eventual pitocins, which has a higher rate of retained placenta and hemorrhage. The key is the rest period between bags and that there is no viable fetus to be conserned about FHR with. Just remember to watch for water tox and use a toco & strict I&Os. These patients tend to do very well.

I think that I saw the same rates and that was for a resourse program if I am not mistaken. Good luck w/ all of that I worked in Rush's perinatal system for over a year now and wouldn't mind working at Rush, I like the intensity but perfer not to be crosstrained. Guess I am old fashioned in that I like L/D and just L/D nights on MBU or in the nursery is not my cup of tea. I have learned from experience that suburban hospitals/ dependant on which system you work for, is actually higher paying. I have worked a few in the burbs and one (got offers from 3) in the city and generally I am making about 8 percent more in the burbs. I still work registry out in the city. Not bad rates either. Either way good luck to you and congrats on your new career. BTW if that was Rush's regular rates, I don't think they would even need to post any position because those are VERY high. $21 is not that bad, actually average for new grad pay. I started at $20.50 straight pay.

Another one comes to mind as for babies just flying on out. Had another multip, was 7cm, wanted to go on her side, BOW intact/bulging, so ok no prob, doc was in the lounge. About 2 min later she says she feels pressure so I go to check her, she isn't even all the way on her back and I see the membranes bulging through, I called out to the tech to call the ob in and give me a hand, so next uc comes and this girl must have had poly cuz, I go back and her bag explodes and shoots fluid across the room and the head is on its way out well I just barely caught that kid, It was quite slippery and was shot into my awaiting hands. beautiful baby, crying and all was good, brought to the warmer and did very well. I on the other hand was soo soaked that I needed to take a quick shower, It was in my hair, down my shirt my underware was soaked, thank god no mec! Well the doc comes in and was in a really good mood, didn't mind that he missed, goes to put on his gloves and by this time the pt was up in stirrups out comes flying the placenta, not just coming out like litterally 5 feet from the bed the thing landed by the doc's feet with a ploop. All he could do was laugh and say that he missed that too. Family and everyone was laughing. Same thing w/ the same doc happened a week later, this time a primip who was 5 cm and still laughing. Next thing I know, I was talking to the doc by the door w/ my back to her and she says " um I think the baby's comming" I literally turn around to see the baby fly out and land at the foot of the bed. I felt horrible. Pt was ok, but was like does that always happen, um no not usually w/ first time moms w/ no sign. pain. :imbar

Well, I have had more than my share of crazy deliveries. The inner city hospital where I work had several OBs that were pretty laid back about rushing in to deliver. So nurse deliveries were not that uncommon. Coupled w/ the fact that some of the ER staff was, lets say, alittle slow on the uptake. No offence to those who are ER nurses. But some just have a few screws loose. One that comes to mind is a few months ago, we had a call from ER a multip cam in and was "pretty uncomfortable" so they wheel her up after registering her, which usually takes at least 10 min. He comes in mom is half out of the wheel chair. ER nurse says "well she is having a hard time sitting, so she must be close" Well his hearing aid must have been on the blink, cuz I could hear a very definate muffled cry. Mom is spanish speaking and is going a mile a minute how the baby is here, ER nurse didn't get the whole pic. I help her to get up on the bed call for help and in one pull on her sweats, here comes baby...screamin up a storm. The ER nurse just looked like oh, well. Lucky all was well. I still can't get over that he didn't hear the crying baby or the huge moving baby in the pt's sweets. Found out from the patient that she was telling them down stairs that the head was coming out, and was delivering in the elevator.

I think I know someone who works at your sister hospital on the floor and hates it. Main gripe is the fact that sometimes by the time that she actually gets to the fax the patient is already in their bed ready to be assessed. It has caused alot of tension between the floors and ER. I am sure that because it is new, and anything new takes time to get the kinks out and some getting used to, that some nurses are having a hard time dealing with it. Also some things (critical info) are getting missed and result in a phone call back the ED and phone tag inevitably ensues. She tells me it is more time consuming than the old fashioned phone call. I guess the plus side for ED is that they don't have to wait to speak w/ the nurse. Otherwise I don't really see the benefit in it. Gotta wonder about continuety of care?

Sorry about your bad day, stick in there, organization and time management come from experience. Days like this are ones that will make you a stronger nurse if you don't let it overwhelm you. Did you care for your patients as best you can? If so then you done good. :)

:rotfl: :rotfl: :rotfl: :rotfl: Trusn: You just saved me from the same nightmare!!!! :imbar Thanks for the good laugh!!!

I'm with you. I too can't stand working postpartum. I like the teaching aspect and all, but would never want to do it even on a semi-consistant basis. I work nights and find it very boaring, to slow paced. I even get board w/ antepartum patients. Guess I need to be were the action is..deliveries, triage and OR.

Interesting test. I work OB currently and that ranked #26 for me. Liked my Emergency med rotation and that ranked near last. My number one was Nuerosurgery followed by plastics. I always thought of myself as more of a truama/cardiothorasic type if I ever ventured into medicine. Wonder how they come to this conclusion. BTW I tested myself twice (used my other email address) same results both times!

Thanks for the good ideas, I will start by speaking to the HR director when he comes back from vaction (every body seems to be on vacation except me;) ) You did hit that nail right on the head Kids-r-us, that is exactly what is going on from my perspective. Once the word "discrimination" entered the picture everyone got very stand-offish on vocalizing any thing or stopping any behavior. I have taken some steps like helping her to another empty room when she acts like this and bringing up the fact that this isn't professional behavior, ie risking patient complaint and a lost job. Told her to think of her kids when she is this upset, that they depend on her. Her reaction, very immature..."I don't give a damn what happens, that is what state aid is for, I will not put up with this....." You fill in the blank. The fact is they are not really discriminating against her, just they do not like the behavior as it causes alot of stress for us that have to put up w/ it. Anyhow I was talking to a friend of mine who says that there is a lawsuit in process for this exact thing from another former staff member who was of, get this, the same culture as this one we are dealing w/. And of course she knows about this and has brought this fact up. I don't know for sure, but it sounds like this is where it is going, gut instincts talking here. Who knows how far this will go. I just really don't want anyone to get hurt.

Hey, Sorry never did thank those that replied, so thank you! A month has gone by and not much has changed. I myself am frustrated. So are others. Our manager is back and fully aware of the situation, yet nothing has been done to my knowledge. So we just go on in this little vortex of ours. Call outs are now weekly, she seems not to have a baby sitter on a particular night and guess what calls in sick. This pay period so far has called out 3 times. I had to tell them I could work OT and ended up calling in because I am sick. They gave me a guilt trip (staffing is very tight). What can you do? I have documented some things and gave them to the NM. Just have to wait and see now. But again in the immortal words of Bartle and James,...Thanks for your support.

Hey all, again asking for advice, but this time not for something that is specifically my prob. I have been working in a community hospital L/D for about 8 months now, love the job, and the co-workers are culturally diverse. Now one culture does override the other, but this is just how it is at this hospital, doesn't mean that they don't hire people from other cultures as I and another co-worker are both ouselves different, culutrally that is. Here's the thing my co-worker is hell bent on accusing our co-workers and now I find myself included in discrimination. She states that we pick on her, make her do more work than others and get the harder assignments. Well to be honest, she doesn't always get the harder assignments, I usually end up w/ them, which is ok as I prefere to be busy and we both just graduated last year, and you can only learn from doing in my opinion. She claims that she got shotty orientation, which she acutally had a little longer orientation than I did and overall wasn't too bad, frustrating at times, yes, and we used to talk about these frustrations, but that goes hand in hand w/ orientation I have now come to that realization. The thing is she is extreemly defensive, you try and help and either she gets offended or does nothing at all. She doesn't try and make it better by atleast appearing interested, she just gets defensive. This has been perpetuating more and more lately and it is becoming a big problem. Now she is accusing everyone of discrimination. Well, guess what, everyone is getting tired of it. She is always behind on charting, has found to be falsifying charting (ie BPs charted are not those off of the dynomap), doesn't act in a situation when it is necessary, doesn't chart meds, charting is usually incomplete and blatently becoming more and more dangerous. Now all my co-workers, those that are a different culture from myself as well, are becoming more and more upset by the situation. This culture is based on respect for your elders and for your fellow humans, and have NOT been picking on her specifically. They give her assignments so that she can learn and become more comfortable w/ these types of pts. She is now to the point of having tantrums, swearing, crying, lies, yelling at everyone, physicians included. She is becoming more and more unable to make a decision and blames everyone else when she ends up making the wrong decision. She outright accused us of being discrimanatory, states that "you are going to pay" for this, and I believe has become threatening. Sufficit to say no one wants to work w/ her, no one wants to be in charge of her and at the same time no one wants to fire her because, she is a single mom w/ three kids and our boss is on vacation (she was very aware of this and has been more than fair w/ her before she left.) This is of course causing BIG problems, physicians are asking for her not to take care of their pts, she is minipulative and just down right irritating. Two nurses are ready to quit. She calls out when she is pissed at us, causing staffing problems. She has involved the nursing supervisors and the nursing director as well. Nothing is outwardly being done. It is out of hand really. I have alot of empathy for her, as I know what it is like to be under alot of stress, and it does change your personality and behavior. But at the same time I DO NOT agree w/ what she is doing. I think she need help and even though this has been offered, she down right refuses it. Its sad really. No body wants to fire a single mom, but they are also afraid because of the discrimination accusation hanging over them. Some of them look to me becuase like here I am the only one of my culture/race on the unit & shift, as is she. I have no problems, and infact find everyone very caring and nurturing to me, as they were to her as well, until this started, now nobody knows what to do. And they talk about it to me because we went through orientation together and used to talk. But the more she became angry the more I stayed away and disassociated myself from her, kinda feel bad but I didn't know what to say or do. Not to mention it is not my place to be the one to make any decision or to be smooting things out, that should be left to the managers. Have any ideas or thoughts?

You all are right in stating that it is not discrimination, bad choise of words, I just feel that it is a select and I mean select few that I had issues with and there is much more to the story than it seems. I guess they hold some grudge against me that it is more like they cannot foregive and forget and move on. True, I don't need it, but I still have many friends there all of which are kinda pushing the issue for my return. So this kinda let me feel that this would be something good. Like I said I do have a good thing going for me now, but I still can't help but missing a place where I truly felt at home, I knew people everywhere there had great relationships with many, and was for the most part treated quit well, with the exception of this little clique if you will, which just so happens to include my old NM, which has in turn stabbed me and quite a few others, in the back if you will, and lead us to believe that she liked us while ending up messing with us in the end. I guess part of it is to prove their perception of me wrong. Why so improtant to me, because at one time I held the utmost respect especially for her, who I felt was more like a grandmother to me, and was terribly let down. You all are right I don't need that kind of aggravation, I am well respected, or so I am lead to believe, where I am now, and enjoy my work. I guess a good way to put it is that like a child who has been scolded I want to prove that I am better than their perception, which isn't entirely right in that there was alot of decit and game playing going on behind my back, by the affor mentioned select few. I guess if you all can understand that would be where I am comming from. I am just frustrated. Especially by the fact why would I get several thank you cards, letters of recognition, great reviews which in turn gave me higher than the standard increases, several official thank yous from directors, staff and other members of the team all to be closed out like this? I just can't understand it.

Ok so here is this situation, and I can't imagine I am the only on in this boat so any advice would be good. I was employed by a community hospital for 7 years as among various positions a tech and a secretary I worked there during my pregnancies, births and through nursing school. When it came time for my graduation there were no positions available in my department and it was suggested that I work outside the organization and get some expereince and come back with this expereince under my belt. This advice was given to me by my nurse manager and mentor. While I admit there have been some problems and I was written up once, which wasn't an event that was entirely my fault, I was given good reviews while employed there and was always the one to do what was expected of me even if it ment me coming in early, staying late switching my schedule around. I was good from a technical standpoint, fast learner and from what I understand well respected by the most of the staff and physicians. I admit that I wasn't always pleasant to work with, under a lot of stress and would come in in a bad mood sometimes, and for the most part I would keep to my self when I was like this, when talked to I would recognize it and work toward resolving the issues, I am also out spoken and probably said too much sometimes but when I left there didn't seem to be any hard feelings and I was even given a goingaway/grad party by my unit. So here I stand ready to go back and on first attempt they asked that I have more experience. OK I can respect that. Now that I have reached that I reapplied and was told that I wasn't a good fit...ok why? So I contacted the director ands was told it was because of my "attitude problem" while I technically was more than qualified for the position that my old nurse manager felt that I would be a problem, d/t communitcation and attitude. Now, that hit me pretty hard. I feel that even though I wasn't always the greatest person to work with I still had a good relationship with most on my unit/shift. I have several nurses willing to back me up and one has gone so far as to mention my name several times to encourage them looking at me as a future member of the team. I also must say that most of this goes back a few years and while I was under stress d/t school and personal family issues that were going on at the time, both of which don't exist any longer, and I have been a good employee for my current employer and have gotten along well with most. I know that personalities will collide and you won't get along with everybody, but that goes without saying. I feel like they are holding a few instances against me and that overall I did get along with everybody. I was always a team player. There are a few that don't even work there or on my shift that ok, I understand we didn't work well together always but for the most part I was liked. What would you all do, I am prepared to fight it, but I feel that it is a select few's opinions that are doing the damage. I am even willing to ask that they speak with the staff I would be working with to see their opinion on the matter and there is as always a three month probation. I really want to work there again, because I have always like the unit, the job and the people, not to mention that it is close (10 minutes vs 90minute drive to my current job) and more money. My question is what do you all think would be a good way to fight this?

In repsonce to Imastork... I have had a midwife suggest this as well, but the House OB refussed to do it stating that a full bladder can cause problems of its own, not to mention that it wastes time, just a gloved hand and repositioning are needed along w/ a quick ride to the OR. Curious to know if it has worked for you???

For regards to the cord hanging out of the lady parts I was always told to try and AVOID touching the cord as that could lead to vasospasm and cause worsening complications, and use a gloved hand to help hold the head off the cervix w/ the pt either in trendelenberg or hand/knee position. The gloved hand should stay put holding the had until delivery is accomplished via a c/s. Absolutely right in that you need many hands in the room to carry this out expediantly. I haven't thankfully had it happen this severly but have had a prolapse into the lady parts and that is what you do call for help, get the head off the cervix, position, O2, IVF and anesthesia, run don't walk to the OR...this is a true crash, esp. when the fetus doesn't respond to interventions. As for the second question. From my understanding it takes 4-6 wks for involution to occur and the cervix to heal from delivery, not to mention the epis and maternal discomfort. I believe this is why they suggest following up w/ you healthcare provider so that a speculum and pap can be done to assure proper healing. My twenty-two cents;)

Hmm, does sound like a HUGE amount of info is missing or protected. This story as it is told is VERY fishy! First off, I agree, how the heck would she have at least 12 hours to travel hospital to hospital looking for the care she wanted if she was in labor at G7P6? Second off, isn't this an EMTALA violation???? Don't they have the right to care regardless of pay and desired care? And where the heck is the primary OB/CNM she was seeing, or wasn't she getting prenatal care?? Of course the OB on call has the right to be concerned, but as for EMTALA they do have the need to carry out proper and expectant care w/ regard to pt wishes, as long as she is given informed consent with all options, possible outcomes and alternatives discussed. I really think that there is a lot more to this story and I really can't see them refusing to deliver the baby if the pt is active (8-9cm) and ready. She does have this right and the right to refuse. However, alot of you are right in stating where do you draw the line? Where would the liability land if an adverse outcome? My guess is that if she sued and the case was documented in the medical records clearly stating her state of mind and that she refused treatment against medical advice then it should be clear that she went into this knowing the posibilities. Like someone else said...WHAT A MESS!!! Would really love to know the whole story, good thread!

Hey Dawn, There have been times where they insist on me shaving. However, that is something I just won't do a head of time as it is not plesent!!!! As for the foley thing, I personally like it, I have a better idea of output and don't have to worry about the ever-expanding bladder. I really wish I could move my pts around more. I have done various positions in bed. Some nurses walk in and look at me like I am from outer-space (hands-knee position...should have seen the look on the face:chuckle ) I would love to try and help chang things, but change is a hard thing to impliment w/o a director and w/ most RNs over 20 yrs experience each.

And who says female docs would be more empathetic?????

Maby the IV in the hand is my personal issue. Have had em', hurts like hell and they are very positional, specially when the mom is pushing or breast feeding. But you brought up a good point bout the epis. we do em on alot of pt...but even worse alot of the older docs LOVE those nice big LML's OUCH!!!! I'd rather have a section then get stuck sitting on a donut for a month. Just me though. :chuckle Dang you found me out... I am indead practicing in Mongolia, aka Generic Inner Chicago City Hospital!!!!!:chuckle

Just wondering what kind of "Old School" practices are your units still stuck on. Take my hospital for example: Sanitary belts for c/s, which of course lands right across the vertical incision line that they all seem to use (for no really good reason other than it may be easier). Persoanlly I prefer the lovely "Victoria Secret" mesh panites we use on the NSVDs instead. Still doing losts of good ole soap suds enemas...always fun trying to run to the bathroom 9 months pregnant and hooked up to an IV, BP machine(which is not part of the monitor) and of course the monitor. Continous FHT monitoring on a 26 wkr here for 3 days of GDM teaching?!?!? Not getting pt's out of bed no matter what. Even using a bed pan for someone who is 2 cm Intact and on pit, just because they are on pit. Starting all IVs in the hand w/ and 18g angio not to mention the pain but these puppies don't infuse well especially when it comes time to push (pt's use their hands too much to start it here). 23 Observation for ALL!!! No matter what the complaint (maby I am exatruating, but it sure seems like it sometimes) Ah, there are more, just can't think of them right now. Wish some things could change as this place is just not progressive in thought. Don't get me wrong I like where I work, but sometimes I just wonder....

I guess I stand on the pro-life/pro-choice line. I have my own personal reasons and own personal beliefs and morals. Depends on the situation, as I am not the one standing in their shoes making that choice. I strongly believe ethic committees should be involved if the gestation is far enough to bring them to an L/D unit in the first place. I also STRONGLY believe in the right to make a professional decision on where you stand and that the hospital should support this, as they made their own decisions whether or not to allow the practice in the first place. There are some very good posts that bring up very good points. Interesting discussion re-hashed. This is just my opinion on this and it is especially clear to me that I have made a commitment to take care of patients and not take sides in this unless faced w/ the situation and the facts first. I try and be open minded--which is not always an easy thing to do when emotions come into play.