When doctors don't listen

I had a prime who was fully when I came on at change of shift. Baby was 160-170 and in poor position but there was good variability with some decreased periods. They were ok letting her continue to have an extended 2nd stage (approx 6 hours) with rest periods of 1-2 hours in between pushing since her contractions had spaced out and we were going to augment her. I was ok with this too but we started to get deep variables and I was certain this baby had cord around the neck. The resident and the ob had been in several times during the shift to look at the tracing. I became really uneasy so I called the resident twice to put on a scalp clip and when she finally came she said it was time to deliver and it was not necessary. She called the ob for delivery and when the ob saw the tracing, he immediately asked for a scalp clip:rolleyes:. I knew this baby would not come out vigorous, and was right. The first apgar was 2. Baby ended up bing ok but my question is how do you get the residents to take you seriously. I am new to the floor and I get the feeling that they think I am overreacting. Judging by the way this baby came out, clearly I wasn't. Advice would be greatly appreciated

Did the use of the scalp clip make any difference in how the delivery was managed?

If you disagree with labor and delivery management you need to use the chain of command.

Altalorraine

I think it would have made a difference in that they would not have waited so long. I was concerned that maybe the heart rate being shown was actually mom's being doubled not baby's. With the scalp clip at least we would have known whose pulse it was and been able to act accordingly. Plus the tracing was pretty spotty at times so we would have had better monitoring. The fact is that as soon as the resident called the ob, the ob put a scalp clip on so obviously he was concerned enough to ask for one. I guess don't know if it would have made a difference but I just don't like to be made to feel like there was no reason for concern.

If you feel the Resident is not responding in the appropriate manner call the staff doc, he/she has the ultimate responsibility for the patient. Make sure you DOCUMENT DOCUMENT DOCUMENT! Don't be afraid of stepping on toes, take care of the patient first.

I think it would have made a difference in that they would not have waited so long. I was concerned that maybe the heart rate being shown was actually mom's being doubled not baby's. With the scalp clip at least we would have known whose pulse it was and been able to act accordingly. Plus the tracing was pretty spotty at times so we would have had better monitoring. The fact is that as soon as the resident called the ob, the ob put a scalp clip on so obviously he was concerned enough to ask for one. I guess don't know if it would have made a difference but I just don't like to be made to feel like there was no reason for concern.

I didn't get from your original post that the tracing was a problem, and as a scalp clip is not therapy I don't quite understand how your difference of opinion with the resident on whether to use one is cause for concern. BTW, did you use a pulse oxymeter to distinguish mom from baby?

Altalorraine

Yes, with a pulse oximeter on, it is easier to tell if the monitor is recording mom's pulse. But in your situation you probably lost fetal recording while mom was pushing and you may well have lost her pulse reading at the same time. A scalp lead is very helpful when you can't get good tracing even when hand-holding the transducer, but, it is possible to get maternal heart rate through a dead baby with a scalp lead, so it doesn't always help you decide which patient you are monitoring.

Chain of command is your lifeline. If the resident isn't listening to you, go to your charge nurse. She's more experienced than you and may be able to get the resident or attending to listen to your concerns if she presents them. Any older, more experienced nurse can help you out until you've been around long enough to have more credibility with the docs. They can also give you helpful suggestions on dealing with specific doctors or situations.

Is it forbidden in your facility for a nurse to apply a scalp electrode? Even in teaching hospitals, I've usually been allowed to apply one if I felt one needed to be applied right away.

i totally understand. i had only been on my unit for about 3 weeks when my patient on pitocin began hyperstimulating. i knew that i had read in my policy that if this occurs the pitocin can be turned off or decreased. of course i did panic. i am new to ob. i turned it off and the resident 1st year, said "you never turn off the pit". i spoke to the chief resident who promptly informed her differently. now i am very cautious with pitocin administration.

bg

Yes were were using a pulse oximiter and yes the nurse can apply a scalp clip if traned to do so but no one there was able to do one so the resident had to be called.

I agree with activating the chain of command in situations like this. Also make sure if there are ANY problems resulting from this sort of thing, you write up an occurence/incident report, making certain your manager and house supervisor are aware.

Great advice Deb.

So often we nurses seem intimidated into not instituting the chain of command and then compuond the problem by not documenting on an incident/event report and/or notifying managers.

Frequently just informing the physician/resident "I am going to have to initiate the chain of command" will get them to rethink their decision.