Tuesday, October 7, 2008

Limited Time Left...

Thank you for everyone's support after the JCAHO incident last week! I'm singing praises that I got 5 days off and a vacation to TN after that! Today the state Health Department showed up, thank goodness they went to visit Mom/Baby and not us!

So as I was leaving today, J told me, "I'm not so sure you need much time left on orientation." No! Don't tell me that yet!!! I WANT more time on orientation! I got blessed with another lovely induction couple, postdates by about a week. They were great! I was very, very, very sad when I left and she was just about complete after working for 12 hours to go from 1/50 and then work with her for 10 hours without a block and then she finally smiled again and I had to walk out the door! :( She almost got me to stay when I took the baby warmer in the room and she asked me "aren't you going to stay and help me?" No..............but I'm heading back in the AM so they're first stop on my list to go visit.

I was pretty proud of myself today, J walked into my room as I was lying my gal back after her epidural. J walked in, and 2 seconds later walked out again. That was as much as she saw of my patient for the day. I did it all on my own, talked to the doc on my own, got the epidural on my own, helped with the internals/AROM on my own...yup, I was proud of myself!

But I'm still not done with orientation, there are so many things that I personally don't feel ready for yet. I want to feel way more comfortable with the actual delivery part. I do great up until the time everything seems to crash down around me. It's a ton to focus on and try to do at once. If you take any time to stop and think it seems like you're behind in either charting, pushing, getting what the doc wants...it's crazy! I have the pieces, it's just putting them together. I haven't Mag'd someone yet, that's not something I'm crazy about doing, but I guess I have to learn it anyway. And as much as everyone on the floor hates it when I say it, I have yet to see any real emergencies. I've helped with some precip deliveries, but no "throw stuff around the room, run down the hall to the OR" emergencies. Not that I ever WANT that to happen, but I'd much rather see/do/help with it when I'm not expected to know what I'm doing than to have to deal with it for the first time when I'm really the one in charge.

And here's my question for Doctors; or anyone in that matter who has an opinion or an idea: if you have an induction scheduled, why do you make it hard on yourself? It seems like we have some docs who make their schedules crazy on purpose, and then get upset at us nurses when things all explode at once. Two induction scheduled on the same day at different hospitals, inductions scheduled at one hospital and clinic/office scheduled at a different location. It just doesn't make sense. I felt so sorry for my gal today, she was post dates, her induction was at our hospital (duh) the doctor had office at a different hospital, so didn't make it over to AROM my gal until after 1300. So this gal labored and stayed 1-2cm on 18u of pitocin for 6 hours with no change. After she was AROM'd and got an IUPC, I was getting 300+ mvu's and ended up backing down to 10mu/pit and she finally made some change. In my own little mind, it would have made more sense to a) do the induction at the hospital where you have your office hours (clear across town), or at least make it a point to AROM your induction (that takes all of 5-10 minutes) put in some internals and make sure she couldn't possibly need anything else until delivery before you take off. I know I'm still kinda new at this, but it's just a question. Answers/ideas are more than welcome!

Question #2: we have had OB hospitalists (laborists) for about a year now. I feel kinda weird asking our OB's what they think of them, so any OB's that read this blog, what's your feeling on them? I seem to have gotten mixed messages from some of the OB's at the hospital, some like them to do assists on C/S, some don't even mind if they do something like internal monitors or even an AROM in a pinch. Other's want absolutely nothing to do with them. You couldn't pay them to let a laborist touch their patient, but yet we hear about it if we interrupt office hours to ask for an IUPC, etc. I'm just wondering what other people out there think...

So no babies today, but I felt really accomplished. I hung in there with an unblocked primip for a good 10 hours, then got the smile after the epidural so I felt like I did something worthwhile today. I'll have to admit, leaving a patient at almost complete is about the worst feeling ever, but J won't let me work overtime...good thing, 'cuz I'm a sucker!

Babies today: 0
Babies total: 18M/15F = 33
Vag:12M/14F = 26
C/S: 6M1F


  1. Wellll....my thoughts as a doula/childbirth educator...

    Yes, sometimes the OB's do make their schedules insane. But your proposition of doing the AROM wouldn't be my first choice either.

    First of all, running the Pit up to 18 milliunits/min is contrary to the package insert, which says that levels over 10 are "rarely needed." Of course I've never had a client who was put on Pit who *didn't* get over 10... The package insert actually says to start at 0.5-2 millunits, and increase in small (2 or less) increments every 30-60 minutes. Going on the aggressive end of that--starting at 2, increasing by 2 every half hour...you'd be up to 14 at 6 hours. I know there is research supporting "high dose Pitocin" regimins...how ever the whole basis of the support is that high dose leads to a shorter labor...and shorter isn't necessarily better if it results in a mom in more pain than is necessary.

    Second, it is quite normal to take *12* hours to get to 4 cm dialated in a first time mom. I think that many health care providers forget this with inductions because they don't see these 12 hours in spontaneous labors--the women are typically at home for a good part of the time. So 6 hrs to get to 2 cm is not really outrageous...6 hrs at 14 milliunits/minute is outrageous though.

    3rd...AROM has its own set of problems--infection, more pain, not having been shown by the research to effectively speed up labor in a woman who is not very far dialated...and the biggest is that it commits the mother to birth "one way or the other." Depending on the OB, that could be 12 hrs, it could be 24, it could be "until signs of infection." If the reasoning for the induction were "soft" (as post-dates often is--was it post dates at 40 weeks 2 days...or 41 weeks 5 days?) it can be advisable not to commit the mother to delivery like that, but rather leave the option to stop the induction and try again on another day (not that most OB's will tell women that this is a viable option, but it IS), or at the very least, stop the Pitocin at dinner time, let the mom eat something, rest for the night, and try to restart in the morning (which...ahem...may not necessarily be the best idea either, since women's bodies are primed to respond best to oxytocin at night, most of the OB's in my area start planned inductions by starting in the evening, not the morning).


  2. Also, it's not always the physician who wants be trekking all across town... if you have privileges at more than one hospital, but have clinic at only one, and your patient chooses which hospital she wants to deliver at- you may not have a choice but to do the induction at one place while you're halfway across town doing office visits!

    I am really hoping to have dedicated office and call time- meaning I am not on call on days when I'm in the clinic!

    Love your blog,