So we were inducing this pt today for macrosomia, and I knew something was off when I first put her on the monitor. Now, I'm no expert, but I knew that I should not be having so much trouble tracing a vertex baby. Just really weird, oblong-looking tummy. I KNEW that baby was not in the right position, but I kept my mouth shut. MD comes to AROM, and baby is really high. Duh, right? Now, I'm thinking that she is going to say something about how this baby is positioned, and she doesn't. So I think it is no biggie. It was her 2nd baby, so if she was breech, they may have let her go vag anyway, right? Well, at 1515 this afternoon, after we had cranked up her pit to 28mu's (per order, of course) and she was still not contracting more than like 4-5 min, another doc from the group comes to see her and wants me to go with her to check her. So she is doing her vag exam, and she feels . . . you guessed it . . . feet! So we do an ultrasound and the baby sure is transverse. Version ineffective, to the back we go! They do the usual suprapubic incision, get to the baby, and her arm pops out. They stuff it back in. It pops out again. Again, it is stuffed in. Two docs pulling and tugging and cannot get a good hold on this baby. I swear, it took them 5 min to get the baby out. And I'm thinking, Damn, this baby is going to be all jacked up. They ended up cutting up vertically on her uterus, and then I'm not sure if it tore or if she cut it again diagonally to get the baby out. Apgars 5 and 8; baby did amazingly well considering. Her L arm was all hanging kind of funky, and the High Risk team called her clavicle "questionable". Breath sounds on the L, sats like low 90's. Baby does not go to the unit, but I swear to you, it did not stop screaming until we got it onto the breast in recovery. The most pitiful, raspy cry - I just know she had to be hurting. Whether something was broken or not, I do not know. So anyway, my question is: what do they do for a broken clavicle, if there is one? And why didn't I open my mouth when I knew something was not right???
Lesson learned. There was something they said to me in school . . . and I've heard it before . . . it's tickling my brain . . . oh, yes! It was simply this: TRUST YOUR JUDGEMENT. I am still learning, but I had the feeling that this baby was all cock-eyed. Of course I put my hands on mom's tummy before I put the u/s on - I just am not at the point yet where I'm dead sure of what I'm feeling. I mean, I can tell the diff between arms and a head, but between a head and a butt . . . kind of foggy. Anyways, from now on, I will be sure to question position before I start pitocin. I did not think that one all the way through. It really should have hit home when she kept having these big accels when she finally started strong contractions.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
You are doing very well. We ALL have learned some things the hard way. I find your humility and willingness to learn refreshing and reassuring. You are making an outstanding nurse!
I agree. The nurses who think they know it all and aren't open to learning experiences are the ones who scare me! The fact that you shared this experience with everyone is wonderful.
It comes with time..that speaking up thing. You will learn this. It protects you too. There is no harm in a quick scan to verify a vertex presentation. And.....its how we learn.
I have learned over my twenty some years that the only bad thing that happens if I speak up when I know/suspect something is wrong is that I may get a negative response from a physician. If I don't speak up there can be many bad things that can happen to my patient. I have gotten very good at being assertive in my communications, not taking those verbal abuses. However, at the start of my career I had many a cry in the break room after confrontations with physicians. As a charge nurse now I always encourage my staff to use me in their communications if they fear a bad response. It is support for them and a learning experience in how to deal with aggresive behavior.
Deb and Peg - thanks for your words of encouragement. And yes, I wait patiently for the day that I am not afraid of doctors anymore. Well, afraid of talking to them, at least. Slowly I get more comfortable with them, one by one . . . Only one "run in" with one on the phone - I was running standard pit because her partner ordered it - she wanted to know why san antonio was not being run and was not nice about it . . . cried like a baby for doing what I was supposed to do :imbar . As my husband says, "they put on pants the same way in the morning."
And you're right - the worst thing that can happen is that I was wrong about something. Safer for my pts that way.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I think you will be an outstanding nurse. Lessons learned. Seems to me you are experiencing your 'trial by fire" we all go through as new nurses. I think you are doing great. Keep asking those questions; we are glad to help you.
I am concerned not only about using Pit with a vertex presentation, but doing AROM when the baby is high. I'm not a nurse, but isn't that a contraindication because of the risk of prolapsed cord?????
Why, yes it does. Yet another thing I did not think about at the time. How do you tell a doctor with her fingers in the pt's lady parts that maybe she should not break the pt's water just yet???????
Unfortunately you don't most of the time. When doing Leopolds you can tell if there is a presenting part in the pelvis, you may not know if it is a butt or a head but usually when there is nothing there you can tell. Sometimes if I am suspicious when the doctor is checking the patient before I give him/her the amnihook I'll ask for the station and dilitation. Occasionally if the head is too high this will give them pause because they are saying in front of the patient what the station is. I have had them say we'll break the bag later!
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I am concerned not only about using Pit with a vertex presentation, but doing AROM when the baby is high. I'm not a nurse, but isn't that a contraindication because of the risk of prolapsed cord?????
Alison
Our dr do not tend to ROM people unless the head is well-engaged in the maternal pelvis for JUST this reason.
Why, yes it does. Yet another thing I did not think about at the time. How do you tell a doctor with her fingers in the pt's lady parts that maybe she should not break the pt's water just yet???????
I used to play dumb when I was new and shy. "So doctor, is the baby low enough for AROM. I'm new and I forget... how low are they supposed to be to decrease the risk of prolapse?" I've done the same thing with positioning. "Ummm, I haven't had too much practice at determining baby's positions yet but this baby feels different to me, like he may not be vertex. What do you think? Can you still do arom if he isn't vertex? What would happen if you did arom a transverse or breech baby? (HINT HINT)". It sounds like you're asking them to impart their vast knowledge to you which flatters their ego. Of course it needs to be said before they've got their hand in the lady parts.
I swear, I didn't have a manipulative bone in my body until I started dealing with difficult or scary doctors :chuckle Fortunately most are great and will listen to RN concerns in my experience.
I used to play dumb when I was new and shy. "So doctor, is the baby low enough for AROM. I'm new and I forget... how low are they supposed to be to decrease the risk of prolapse?" I've done the same thing with positioning. "Ummm, I haven't had too much practice at determining baby's positions yet but this baby feels different to me, like he may not be vertex. What do you think? Can you still do arom if he isn't vertex? What would happen if you did arom a transverse or breech baby? (HINT HINT)". It sounds like you're asking them to impart their vast knowledge to you which flatters their ego. Of course it needs to be said before they've got their hand in the lady parts.
I swear, I didn't have a manipulative bone in my body until I started dealing with difficult or scary doctors :chuckle Fortunately most are great and will listen to RN concerns in my experience.
RaeT,RN
167 Posts
Lesson learned. There was something they said to me in school . . . and I've heard it before . . . it's tickling my brain . . . oh, yes! It was simply this: TRUST YOUR JUDGEMENT. I am still learning, but I had the feeling that this baby was all cock-eyed. Of course I put my hands on mom's tummy before I put the u/s on - I just am not at the point yet where I'm dead sure of what I'm feeling. I mean, I can tell the diff between arms and a head, but between a head and a butt . . . kind of foggy. Anyways, from now on, I will be sure to question position before I start pitocin. I did not think that one all the way through. It really should have hit home when she kept having these big accels when she finally started strong contractions.