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RaeT,RN's Latest Activity

  1. RaeT,RN

    Pitocin titration

    I guess I should add that our Pitocin bags are mixed BY PHARMACY (10 units in 500cc D5LR) and stored in our Pyxis. We do not mix our own Pit for induction; following delivery is different. With a doc's order we will put Pit in the IV fluids (LR or D5LR) infusing; 20 units if there is >500cc left in the bag, 10 units if there is
  2. RaeT,RN

    Pitocin titration

    Our Pitocin protocols are either "Standard" (begin at 1mu and increase by 2mu q 30 min for a max of 20mu/min) or "San Antonio" (begin at 2mu and increase q 40 min as follows: to 4mu, 8mu, 12mu, 16mu, 20mu.) 20mu is our max without a doc's order. My eyes are bugging out of my head at you guys who say you've seen Pitocin infusing at >30! If the doc wants my pt's Pitocin >20mu's/min, I want an IUPC. Personally, I have never pushed Pitocin past 25mu/min and would never feel comfortable doing so unless I had cold, hard MVU's in front of me. Also, there are only a few docs at my institution who will Pit VBACs. We had one doc several years ago who would titrate his own Pitocin without telling the RN. That did not last long. Uterine hyperstim is defined by our P&P by a persistent pattern of >5 contractions in 10 min, u/c's 90-120 sec. I am currently serving on a process improvement team at my institution looking at the safe administration of Pitocin. I will keep you updated on what we come up with and what changes come about on our unit as a result.
  3. RaeT,RN

    Maternity/OB Clinical Specialist

    I'm bumping this thread because I'm wondering if anyone has some more info for me. I am currently an RN with my associate's degree. I have one year L&D experience. I have decided to go back to school and believe that CNS is the way to go for me, with a focus in Maternal-Child nursing. I live in NC and was looking for some advice about programs. I'm planning on beginning work for my BSN ASAP. Any advice?
  4. RaeT,RN

    Cerclage at 19wks

    That's why I was baffled too - I couldn't see why she would not give her some Terb at least to see if it would quit the cramping. She really seemed like she was writing the pt off to me, that's why I was upset by the whole thing. I just thought maybe the pt should be obs'ed longer and then a decision made about the cerclage.
  5. RaeT,RN

    Cerclage at 19wks

    Ok, so I have a question. We have this new doc on our unit, fresh out of residency, who does some strange things. For instance, she puts "preeclamptic" pt's with 130/70 bp's, trace proteinuria, normal reflexes, no visual disturbances, no HA, etc on Mag, has them wear SCD's and gives them bathroom priveliges. ??? She calls up to our unit from the ED 2 nights ago and says that she has a 19wk pt down there with a cerclage who is experiencing cramping. Now, our rule is that pt's do not come to us unless they are 20 wks or greater, otherwise they recieve their care in the ED. Anyways, she says that she wants to send the pt up to us and have us get her on the monitor to see if she is in active labor. She then says that she wants us to set up in the OR so she can clip the cerclage because she can't have her tearing her cervix since she is cramping. Now, I'm still kinda new at this, so I just want to know: at 19 wks, we're not going to get anything on the monitor, right??? And I don't know why she placed the cerclage in the first place (don't know at how many weeks it was placed) if they weren't going to try to get her to viability. What does it take from the uterus to tear the cervix from the stitch anyway? Does this make sense to you guys? End result, the pt does come to us, she does clip the stitch and when we left, membranes were bulging in the vagina. Any thoughts?
  6. RaeT,RN

    VBAC with little to no interventions (super long)

    Thanks so much for all your input! I definately agree that it is a control thing; especially with ending up with a c/s the first time, not at all how she wanted things to go. . . not sure if they were scientologists or not. . . The more I think about the whole situation, the more I AM inclined to speak with my nurse manager about it. The thing about this MD is that she is constantly asking the nurses to cover her butt (ie. "I'm sorry, but my daughter is in bed and my husband is asleep, so I will not come up there tonight. Tell the pt in the nicest way you can that I'm sorry no one saw her today, but we're confident that she's stable and I'll see her in the morning." NOT KIDDING. This happened a few months ago.) I really felt that she had put me (well, all of us, really) in a sticky situation and believe that something was missing in the communication between the two of them earlier on. Not wanting to be the bad guy, I'm sure she just decided to let the nurses deal with the pt when she came in in labor. The pt had a birth plan, too, so you'd think all of this would've been discussed before she hit the door.
  7. RaeT,RN

    VBAC with little to no interventions (super long)

    This is exactly where my anxiety about the whole situation stems from. Trying to do right by her, but in doing so potentially doing the wrong thing for the baby and paying for it later. I like the idea of a "debriefing" with the pt afterwards. Thanks for the suggestion! The pt was very pleasant afterwards in recovery, and when I transfered her to her PP room she thanked me for being so accommodating, saying that she knew a lot of their requests were "different".
  8. RaeT,RN

    VBAC with little to no interventions (super long)

    Yes, this doc WAS the pt's primary MD. She told me that she had been hoping she was not on call when the pt came in in labor. The pt had actually been referred to this MD by a midwife in a Birthing Center, for obvious reasons. To hear the MD talk with the pt at the bedside, it sounded like some things had been discussed in the prenatal period. She signed our VBAC consent (which is really scary and lists all the possible risks to VBAC: uterine rupture, hysterectomy, fetal death, infection, adverse drug reaction, maternal death, etc. - basically the biggies and any possible postsurgical complication - all meant to scare the pt's out of attempting one, I'm sure) once in the MD's office and upon arrival to the hospital. I just wonder what the MD's inital response was when she met the pt and what was said when she learned the primary was for CPD? Moreover, taking the "energy advisor" into consideration, I wonder what else was said to her by non-medical personnel? I forgot to add that I was also chastised when I strongly encouraged the pt to push again with everything she had and told the pt that the MD was coming to evaluate fetal descent and if she had not moved the baby considerably, then she would most likely suggest c/s delivery. The pt claimed the baby HAD moved and her energy advisor told her she was the only one that could know that because she was the mother and the goddess. Now, I know that there is much importance in remaining positive, but . . . The first child is a perfectly healthy 3 year old. She also pushed for 2-3 hrs to no avail.
  9. Ok, so I've been missing from the forum for a while. . . just caught up in some things here and there. . . computer on the fritz for a while. . . forgive me for being MIA for so long, and I absolutely must vent. Now, the experience I had the other night I will never forget. This is like one of those nightmare situations that I've been sure were eventually coming my way. Maybe I overexaggerate; not exactly a nightmare, but a very difficult situation. Number one, coming up on one year of experience as an L&D nurse next month, there are still many things I am not completely comfortable with. Logically, I know that VBACs most often result in normal, healthy deliveries. That being said, I still have an unnatural fear of them. I arrive at work on Tues and I see on the assignment board that I have a VBAC pt. The anxiety begins. I get report and am informed that upon arrival the pt and her husband were requesting no intervention whatsoever, refused EFM, refused an IV, refused GBS prophylaxis. . . the nurse before me somehow convinced her that the EFM had to remain on. The pt progressed pretty well through labor on first shift, breathing through her contractions, but it was too much for her and eventually when she was exhausted, begging for help, and offerred an epidural, she took it. Go figure. But, just because she had broken down and gotten the epidural did not mean that she was suddenly open to everything else. Eventually they found in the lab report that her GBS status was negative, which was a relief. At least we dodged that bullet. So by the time I come on, the pt is pretty comfy with her epidural. The room had to be kept dark and silent. I was nervous walking into the room, but was advised by the nurse that I got report from to let the pt have as much control of things as possible, and that for the most part, the pt really was agreeable if you communicated openly with her and allowed her time and the freedom to decide when she was ready for SVE, etc. That is the way it should be with every pt, right? Well, I am in the middle of my assessment and the MD calls. So I give her report and she is very open about the fact that she is tired of waiting for this pt to deliver. The pt by this time is 9.5 cm, still intact. She is refusing AROM because she wants the baby to be born with "the veil". The MD tells me to somehow get the pt to be agreeable to a foley so the baby will come down. (May I add that her primary c/s was for CPD.) So, giving the pt the option of a straight cath or an indwelling cath (remember in Peds when they told you to give the 2 year old the option of taking medicine with juice or milk? That's what I though of with many things with this pt), she opts for the straight cath. So after the cath, while she is on her back, she has a couple of lates. Nothing major, just subtle and non-repetitive. I turn her to her side and her strip is still suspect. So now I have to convince her to wear 02 ("Can I just breathe deeper?"). I call the MD and tell her that the strip is suspect and that I think she should come to evaluate. By the time the MD arrives, the pt is complete with membranes bulging out of the vagina. I'm thinking, thank heaven, that we're in the clear. Over the course of the next 3 hours, the strip deteriorates. She begins to have variables. She is pushing intermittently in her own way, which is fine, but the baby is not descending. We turn down the epidural rate to help her be more mobile. Hands and knees, squatting, nothing is working. A continuous tracing is very difficult for me because the pt is so all over the bed. We begin to have what I feel in my heart were lates, but it is so difficult to tell because the pt is changing position so frequently and the monitors are having to be adjusted. Often, what I believe was the maternal HR (verified by palpation) is tracing intermittently. The MD comes back and suggests internal monitors to the pt to better monitor her baby. Of course, the pt refuses. The MD tries guided pushing with one contraction, but the pt is not receptive. The MD is obviously stressed about the strip and you can see it on her face while she is at the bedside. The MD leaves me with the pt, after pulling me in the hallway and telling me to start mentally preparing the pt and husband for a c/s. So I again attempt some guided pushing with her because even at a lower rate, her epidural is still pretty dense. She refuses to push further until her "energy advisor" comes from the waiting room to help her. The MD is angry and tells me she is giving the pt 30 min, then calling the c/s. I tell her that I will do my best to get the pt to push. The "energy advisor" comes; the pt asks for guidance, silences me when I ask her if she is ready to push. The MD calls into the room to ask me to get the baby on the monitor. The pt is exasperated that I must continue to adjust the monitor. The "energy advisor" tells the pt not to worry, that she will not need a c/s and that the baby IS coming down, but it is the medicine from the epidural that is making him sluggish to come out. The MD comes after the allotted time, gives a short lesson to the pt and husband on EFM, explains the late decels and recommends a c/s. The pt and husband agree. Then I just had to get her ready. The pt's husband tells me to remember that everything must be as silent as possible. No one else cares who is helping me to get her ready. It takes me longer than usual bcuz the pt wants to prepare herself for everything (Bicitra, shave, leaving the room, etc.) and my coworkers are like, "Come on, already! Get her in there!" End result, mom and baby are healthy. Wish I had a cord gas to report, but I don't. Apgars 8/9. I am upset because I wanted the pt's birth experience to be everything she wanted it to be, but at the same time, how do you allow for that and be sure that you are doing the best thing for the fetus? I made sure to document like crazy every single time the MD came in the room and talked to the pt and reviewed the strip and the pt's responses to everything. I am still worried, though, because she was having decels for 4 hours until delivery time. Granted, there were only repetetive lates (though still hard to tell because the monitor were constantly in need of adjustment) for the last hour, but that is still too long for me. The MD was very open about her frustration with the lack of control she had had with this pt through the course of the day and at first had this attitude like she wasn't even going to try suggesting anything because the pt was going to do what she wanted anyway. That attitude upset me because I felt like she should not have been resentful of the pt for wanting to maintain control, and that she still had a duty to care for that pt, no matter what. Finally, though, she could not ignore the strip anymore and I just wonder did she wait too long? Was I remiss as the nurse in this situation? What could I have done better? I have learned how to be. . . diplomatic with pt's and most often can get them to agree when the situation and reasoning behind interventions is explained to them, but this pt was extremely difficult to do that with. Thanks for reading. Feels better to get that out. Any input is appreciated.
  10. RaeT,RN

    Sta C/S

    We always have kits in the OR ready to open up for emergent cases. As part of our orientation in L&D we have a week of scrubbing . . . not that that means we are completely comfortable doing it if we ever have to. We always have a scrub tech in house, and we feel comfortable at least opening up if we had to. I wish that we did have a tray or kit of some kind close to the nurse's station if we needed it. . . we had a mom code about a month back and nurses were running back and forth from the labor room to the supply room (which is in a central location, but still. . .) to get the MD and the scrub tech what they needed beyond just the C/S tray with the instruments. Thankfully that did not happen on my shift, or on night shift for that matter, but the story scared me all the same - the whole idea of being caught unprepared.
  11. RaeT,RN

    In the right place at the right time........

    Wow, (to the OP) way to be right on the ball. I know that generally VBACs are perfectly safe, but they make me very nervous for this reason. The epidurals scare me the most with these pt's - will they still feel the rupture if they have a heavy block, or is your first clue FHT's in the 60's?
  12. RaeT,RN

    LDRP new grad

    I am also a new grad. I have not had children yet, either, but I work with several women who have been doing this for many years and never given birth themselves, either and are incredible nurses. Nights are not that bad. Just take some getting used to. I actually like them better than working days. I am a night owl anyways. It is (typically) slower on nights and, like Fergus said, you develop as a professional because you are so independent. Feel free to PM me anytime. Good luck.
  13. RaeT,RN

    Why did YOU choose OB nursing?

    It was the sheer amazement of the whole process for me - and, to be a positive part of such a huge moment for women and their families. I absolutely LOVE my job and really believe that I am where I am supposed to be. I must say, though: I am a new grad coming up on 9 months experience - you guys, this is NOT a cushy area of nursing. It is very hard, and nothing prepares you for it. 95% of the time it is the happiest place on earth, but the other 5% it tears your heart out and makes you question your decision. It is worth it if you do decide to go into it, though, but just remember it is stressful and (as Deb likes to say) the learning curve is very, very steep. Best of luck to you as you finish school!
  14. RaeT,RN

    AWHONN convention in Baltimore

    I wish I could go! I'm a teensy bit further south than you guys (plus I've already booked my vacation for that week). I went to the NC state conference last Fri - very informative.
  15. RaeT,RN

    Doula Thoughts on L&D (long)

    As always, Deb, well said. There has got to be a trusting relationship between the healthcare team and the pt. I don't have a lot of experience with doulas, but the whole feeling some have that the doula must "protect" our pt's from us bothers me. It is my job to advocate for the pt and to develop a relationship with that pt. YES, some interventions are done purely for convenience, but as previously noted, many are not and are infact necessary.
  16. RaeT,RN

    Gift for Antepartum unit

    I can only imagine what you must be going through right now. Anything you do will be very much appreciated by every nurse that took care of you - whether it is a card or some other kind of gift. I'll be keeping you in my thoughts.