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I had a pt who was a G2 P0 receiving cytotec overnight. Pt rec'd nubain at midnight around 4am was crying in pain, shaking and throwing up. Resident said to check pt and call her for an order for pain meds. I checked the pt. thought she was 5 and had another nurse check behind me because I am new and still not 100% comfortable with exams. She called her 6. Resident ok's order for an epidural, pt gets the epidural and is able to sleep. Resident comes in an hour later checks pt and says she is 1!!! Pt's dr comes in and finds out she is 1cm and pitches a fit in front of the pt and her mother and tells her it will be very difficult for her to deliver vag because she got the epidural so early! I was furious! I have had docs order an epidural on a pt who was ft because they were a "hard exam" Any thoughts?

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I was shocked when a patient of mine went from 8cm to 4cm. (She had been checked by Dr, myself and another nurse - so she was certainly an 8). I was told that the cervix can swell and that is what makes the dilation regress. Atleast in her situation that was the case.

Yes it happens.This is not reverse dilation, however. This is swelling.

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Specializes in L&D.

I'll bet I know what happened. Wish I had a pen and paper so I could draw you a diagram, but I'll try to explain it to you. Sometimes the external os dilates and the internal os stays 1-2. When you do the exam, you feel the ring of the 5-6cm external os and what usually feels like bulging membranes. I always try to slip my fingers between the os and the membranes. If I can't, I know I have to keep looking. In this situation the internal os is usually very posterior (logically it should be in the middle, but it isn't--go figure) and the cervix is truly "paper thin". A friend of mine used to call it "nylon stocking" thin.

I once had a doc try really hard to rupture membranes on a patient who was 6 cm and she was amazed at how strong the membranes were. She described them as like vinal. Later when I checked her I found that the doc had been trying to rupture the cervix. The patient's cervix was 2cm/110% effaced and very posterior. This doc wasn't even a resident!!

I don't like to see epidurals given that early, there is a higher number of malpresentations when it's given early (posterior, asynclytic, etc), but that can be managed. Move your patient around frequently. From side to side every hour or less. And by side to side, I don't mean from left tilt to right tilt. I mean from 3/4 prone on one side to 3/4 prone on the other and everything in between. I've seen patients get an epidural before an induction was started. Not my favorite way to run a labor, but the choice isn't mine.

As for the resident... Would you be comfortable talking to him about it? Acknowledge your mistake but let him know that you're upset that he yelled at you in front of the patient. As my shrink taught me, use "I" messages. Not "You were wrong to yell at me," but "I felt upset when you yelled at me in front of the patient. In the future, I would appreciate it if you'd talk to me privately if you have criticism to make." You've told him how his behavior affected you and how you'd like him to act in a similiar situation in the future. Whether or not he does is his problem, not yours. You've stood up for yourself by reacting assertively, not agressively, and telling him how you expect to be treated. It's a difficult, but invaluable lesson to learn.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

I agree that getting epidurals at very early intervals is not ideal. But there are times when this may be necessary. I have seen this particularly in very, very young patients or victims of rape or incest. It can be a life-saver in certain cases, and yes, even before induction of labor or the first cervical check is done, we have done this. I think this is a good reason, myself. There are always cases where you need to intervene early, and you have to adjust in such cases and hope for the best.

I also agree, any patient who is in labor, you must move, move--- move. Labor epidurals, particularly, this is sure the case. I recommend moving positions every at least 30 minutes when awake, if at all possible. Being flat on the back or stuck in any one position really is the enemy of progress, even more so than the early epidural. I have had many a patient "stuck" at a certain point, become complete just by moving her from one side to another-----Good point!

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Although I am still fairly new in L&D (I have been a nurse for over 20 years), my coworkers and I have had the discussion a number of times. In presenting various scenarios for us "newbies", we have discussed swelling, time of epidurals, differing cervical checks.

As far as the cervical checks, as some say "it happens". I have had a discrepency with a resident and felt horrible. But even my preceptor had the problem after me with another patient. I believe there are just so many human variables that the differences will continue to exist. No one is perfect. We should all look at these as learning opportunities and not beat ourselves up about them.

Timing of epidurals is entirely an individual thing. I think that if there is a patient that is so uncomfortable that other things are not working an early epidural may be necessary. I have seen patients in tears with cervadil, contracting to beat the band, and still not dilated very far. IV meds did not work. An epidural was the only remaining option. Things progressed nicely after that and the patient had a more positive labor experience with healthy baby at the end. Just depends.....

I would definitely support what others have already posted... don't take it personal. You can only do your best and continue to keep learning and honing your skills.

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Specializes in Labor & Delivery.

My big SVE discrepancy story is kind of funny. I was doing an internship in L&D during my senior year of nursing school. I did an SVE, called it 5 and then my preceptor checked behind me. She looked disappointed and told me she was only 1cm. I was bummed because I'd felt pretty confident and it wasn't a difficult SVE.

We started Pit and then rechecked her a couple hours later. I still thought she was 6 or so, but again my preceptor said she was just 1 cm. The pt was up to the bathroom shortly after this and I noticed some really fresh, undiluted looking mec.

Turns out that this baby was an undiagnosed breech and that my preceptor had been finding the baby's orifice!

Wild, huh?

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