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.
RNnL&D
323 Posts
I agree with everyone else. The patient should have been informed ahead of time of what is involved with a VBAC as far as hospital protocol. I'm glad you were able to empower the pt and allow her to make decisions for herself. As fas as pt not following protocol, difficulty monitoring, etc., all you can do is document, document, document.