VBAC with little to no interventions (super long)

[RaeT,RN]

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 lady parts. 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.

[rn/writer, RN]

Seems like with a VBAC, the doc should have explored the patient's thoughts/feelings regarding the various possibilities during the prenatal period. Especially with CPD being a factor. That doesn't usually bode well for a VBAC, in fact, some OBs consider CPD a contraindication to VBAC.

If I were an OB with such a patient, I wouldn't agree to a VBAC unless she was fully informed of the risks AND the tools to monitor/manage those risks and furthermore had agreed to their judicious use. How in the heck can the doc know the VBAC is still a viable choice if the parents won't allow that information to be gathered.

Yes, we all want the mom to have a great birth experience, but her emotional needs should not outweigh the baby's need to get here safely. Don't get me started on the "energy advisor."

Again, the time to discuss all of this would be well before crunch time in the delivery room.

Two questions. Was the doc the mom's primary OB or an on-call MD? Did this doc/practice handle the delivery with the CPD (and what was the outcome with that baby?)?

[RaeT,RN]

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.

[SueBee RN-BSN]

Oh boy!!! what a time you had. Sounds like everyone was just fed up with the patient. From a legal stand point this MD was, I'm sure, frayed. When patients have good doctors, and nurses they should listen to them. Doctors and nurses are working to see to it that mom and baby are safe and healthy.

[htrn]

Prior to becoming a nurse, I had three children and #4 while in college. My first two were c-sections for fetal distress/CPD and failure to progress. It could be said that I was obsessive about having a successful VBAC for 3&4, and I did. (I actually had three versions with #3, was ruptured for ^36hrs with mec, etc...:trout: ) I can understand how some patients may feel that 'medical intervention' leads to c-sections because I felt that way myself - until I learned better from experience on the 'other side of the blanket'.

You did the best that you could and documented appropriately - and bottom line, you had a good outcome.

What I like to do after a patient has an unexpected C-section is try to take time and sit down with them after they start feeling a little better and 'de-breif' them. Ask them if they have any questions about what happened, why things happened, etc... I like to give them an opportunity to discuss their feelings with their 'labor/delivery' nurse. I also like to tell them that it is possible to have two C-sections and then VBAC, but that there are significant risks, etc... I want them to know that I understand how disappointing it can feel to have a 'failed' VBAC for 'failure' to decend, 'failure' to progress, etc... That conversation may also help you feel better about how you cared for your patient.

Don't be discouraged, you will see similar situations over and over again - people think they know better than their docs, etc...

You done good kid

[gr8rnpjt, RN]

No doubt if something had happened to the baby the "goddess" would be only too eager to sue.

[RaeT,RN]

No doubt if something had happened to the baby the "goddess" would be only too eager to sue.

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".

[SmilingBluEyes]

I would talk w/the manager about this---as well as the physician involved. What do your policies say about TOLAC/VBAC and did you stick to these?

The doctor SHOULD have LONG AGO established the ground rules for TOLAC/VBAC according to policy, with the patient. That way, if she was not agreeable, she had the chance to change venues (perhaps in a Midwife-run birthing center or at home, as is certainly her right to do). Our docs make it eminently clear the following is required to TOLAC where I am:

-Saline lock established (no exceptions)

-Continuous fetal heart monitoring (again no exceptions---except to get up and go the bathroom, she must remain on the monitor).

-A very clear and concise consent form is signed by patient upon admission,which spells out the requirements, as well as risks, of TOLAC/VBAC deliveries in our institution.

We are the only hospital in quite a mile radius that even does TOLAC anymore.....and people come from miles around to do this where I work. I am glad we offer this to people, but risks do abound and bad situations have come up that taught us what we must do if we are to keep offering this service to our patients/familes.

The patients nowadays are well aware of the requirements/their rights when they come in. Our doctors make this clear and spell this out early-on in their pregnancies. This type of situation is rare due to this, and that is a good thing.

I feel for you. I have been there with a very tough patient and family---and baby going bad----fortunately, the outcome was good----but we were lucky, pure and simple. The patient was impossible and her baby was not good when she intially was born. Spent a week in the SCN after birth, due to complications/problems. Part of this was due to the lack of constant monitoring (and therefore, early recognition of the problems coming up) and ability to stay on top of the situation on our parts. Now, I know what the literature has to say about fetal monitoring and outcomes, but in high risk situations like VBAC/TOLAC, the rules are wholly different. Believe me, Had things gone really badly, we would have had no leg to stand on a lawsuit situation. It gives me chills to think of this now.

Things have definately changed since then....when the Chief of OB, the other OBs, Risk managers and the unit manager had their meeting after this, the rules/procedures were more strictly defined and are adhered to. ONE bad outcome, and you have no leg to stand on. That is why I suggest a meeting w/your manager regarding this situation, as well as the doctor.

It's up to the doctor to set the tone, early-on, so you are not in violation of policy/protocol in the future. Make sure you are very aware of your TOLAC policies and stick to them, to the letter. If you have problems in the future, elevate them to your charge nurse, the house supervisor, and the OB Chief, if necessary. Failing this could land you in terribly hot water otherwise......

HUGS---I feel for you. VERY tough situation for all involved. Sounds like you did the best you could and no one can fault you for that. I know you care about your patients and babies.....your conscientiousness is clear in all you post.

[palesarah]

Were they Scientologists? Bringing in an "Energy advisor", asking for absolute silence for the birth... imteresting.

[rpbear]

My charge nurses always seem to assign these "special" pt's to me. It is sort of a running joke on the unit. Anyway, I have found that mostly this is a control issue, these people want a way to be in control of what is sometimes a very out of control situation. I have had a nutural delivery and you do feel like you are out of control of your own body. I have noticed that mostly they just want to be listend too. Don't talk down to them, don't tell them what to do, or what is "allways" done. They want to feel like they are getting individuallized care. They are scared and feel out of control, just help them through the situation as best you can. Explain everything! Give them lots of time to discuss and ask questions. Of course if there is any kind of emergency than this all flies out the window, let then know this up front that there are situations that maycome up that will change the plan. I have had great outcomes with all of my "special" pt's, some the way the wanted it, some the way it was medically needed.

Good luck with all of your "special" pt's, each experience will help you through the next!

[SmilingBluEyes]

Just wanted to make another note here.

Just yesterday we had a TOLAC that sadly,failed at the last minute. The pt pushed and baby tanked---and fast. When they went to open her up in OR, a small portion of baby's arm and hand were waving through a nice little window in the old incision in the uterus. No s/s prior to this, the labor was uneventful and things going very well. And patient was an excellent candidate for TOLAC/VBAC. Of note also, the uterus itself was nearly transparent in the spot around the window.....can we say, scary?

Just goes to show you never know...and how risky this really can be in some cases. That is why I say, know your policies and protocols and stick to them strictly!!!! Can't be too careful EVER.

[RaeT,RN]

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.