Nov 262012

“We’re going to have to do another cesarean section.” – L&D Nurse to mother who was trying for a VBAC, when the baby had some decelerations in its heartbeat.  The OB stated “Nope, we’re going to start pushing.” The baby was born vaginally.

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 November 26, 2012  birth, Fetal Monitoring, L&D Nurse, OB, pushing, VBAC  Add comments

  22 Responses to ““We’re Going To Have To Do Another Cesarean Section.””

  1. Yeeeah. Take that.

  2. Nurses: please do not try to play doctor. Please do not make diagnoses, especially when a doctor is present. And please, please, please do not undercut the mother’s efforts.

    • In most medical settings diagnosis by a non doctor/PA/etc is grounds for write up/termination. Wondering why this is acceptable….

    • Honestly, she wasn’t “playing doctor” by making a diagnosis; nurses make nursing diagnoses all the time and are trained to assess the situation and anticipate the next step. Where she failed was in, as you rightly said, undermining the mom’s efforts and assuming the VBAC was impossible based on one decel. I’m glad the doctor corrected her. If she thought they were heading toward a section she should have simply pointed to the tracing and asked if the OB wanted her to get anything else ready for this birth.

      • Declaring the need for a c-section isn’t a diagnosis? Well, I guess it’s not “Well, it looks like a case of cephalopelvic disproportion,” but on the other hand, the nurse has made a statement that leaves no room for doubt: “We’re going to have to do another cesarean section” sounds very close to diagnosing a permanent, unsolvable problem to me as a laywoman.

        I like the way you have it at the end: asking the doctor if s/he wanted her to get anything else ready for the birth is a nice, under-the-radar way of saying “Should I prepare your patient for surgery?” The laboring mom might even hear that as “birth is imminent and that’s why they’ll need more supplies.”

    • It’s certainly not like doctors always know exactly what’s going to happen. I was told by two different doctors that it looked like I would probably have to end my TOLAC with a repeat c-section. My beautiful baby girl was born vaginally less than 20 minutes later. Being a doctor doesn’t mean you’re omniscient any more than being a nurse means you’re not.

      • No, but being the doctor DOES give you the scope of practice to diagnose and recommend surgery — and being a nurse does NOT.

        The issue here wasn’t who was right and who was wrong. The issue is the nurse stepped outside her legislated, regulated scope of practice — and in my experiences as a pg woman and as a volunteer with pg women with HG, nurses to this to pg and labouring women a lot.

        Good for the doc for pushing her back into her scope.

  3. To the L&D nurse:
    In the words of Michael Kelso, “BUUUURRRRRRRRNNNNN”!

  4. Wow, a regular submission AND a thoughtful thursday submission on the same day.

  5. This was said to a doula client of mine. She was really working for a VBAC and when the nurse said this I could see in her face how much it upset her. I was really glad when her doctor piped up and contradicted the nurse. The decels were from baby moving down the birth canal and after a few minutes of pushing, her healthy baby was born and she got her VBAC.

    • The decels were from baby moving down the birth canal

      The implication here is that this nurse had never watched the monitor before during a birth, or that s/he had never seen a vaginal birth before.

      • I wouldn’t doubt it. There was no checking the mother for dilation or asking her if she felt pressure, just jumping right to the C-section comment. Once the OB checked the mother and saw that her baby’s head was *right there,* he encouraged the mom to keep going. The mom had had an epidural and a much needed nap until right up to those decels, so having to wake up and hear a nurse squawking about another C-section nearly killed the mom’s determination.

  6. So…we only like it when nurses undercut/diagnose/get around rules when it suits us? When WE think it’s right? Like when the policy is no food but the nurse slips in a granola bar? Like when a nurse says to an OB resident: ““No. You can’t just come in here and check her whenever you like, she’s finally found a good rhythm.”

    Like when the NURSE tells a mom that forceps aren’t a good idea? “Don’t let him use the forceps.” – L&D nurse whispering to laboring mother

    Like when a doc orders a a blood glucose for the baby just after birth and the nurse holds off and acts busy for a bit so that the results show up better for the BFing mom who doesn’t want to supplement?

    I’m just sayin’, is all.

    • No we dislike ANY health professional who undermines their patient in any manner whether they are a nurse OB or other….

    • You have a point. I guess I see it as who’s advocating for the mom, and whose job it is. When the nurse says “Don’t let him use the forceps,” she’s wrong — but she’s wrong for two reasons, first because the mom is in no position to do anything about it, and secondly because she’s undercutting the doctor. The undercutting the doctor in that case is actually upholding a right the hospital grants the mother (the right to informed refusal) so the nurse is working with the higher authority as opposed to her immediate chain of command.

      Same with a resident coming in to do a VE — the nurse can advocate for the higher authority (the hospital-granted right to informed refusal) rather than the immediate authority (the doctor who comes in and doesn’t give the mom a chance to refuse.)

      When a doc orders a blood glucose test for the baby, and the nurse messes around for “a bit” (I assume an hour) so the results show up better for the BFing mom, I also assume the nurse knows how long you can go without really messing up the results. If the baby truly has a problem, won’t it show up an hour later? If waiting an hour is going to solve the problem, then it’s not really a problem, is it? But if it’s a real problem, it’ll still be there in an hour.

      When the policy is “no food” and the nurse brings in a granola bar, she’s breaking hospital policy. But the mother herself isn’t bound by hospital policy, and it’s the mother’s informed decision to eat the granola bar. ;-) Because actually, the mother’s authority trumps the hospital’s authority. Again that patient bill of rights thing. Since NPO requires the mother’s voluntary cooperation, the mom can take it on herself to voluntarily not cooperate.

      So I see what you’re saying about rule-breaking, but in the case of this quote, the nurse is undercutting the authority of the doctor (who is right there in the room) and not advocating for the mother’s interests (stated interest to have a VBAC).

      • I had a whole comment typed out, but it got lost and then you said it better anyway, Jane. The nurse’s first responsibility is to advocate for her/his patient while applying high quality, evidence-based care. That includes honoring the patient’s right to autonomous decision making, and it includes telling clueless residents to back off when they’re hyper-focused on checking off their skills for their 6-week rotation through that department instead of paying actual attention to our patients’ needs.

        • In addition, I think some of this is “cya”-ing and avoiding potential litigation versus acting in terms of getting the best outcome for the patient – physically, emotionally and mentally.

    • NO — we like it when nurses do their job withing their scope of practice — and all the things you just mentioned, save perhaps the forceps, are within a nurse’s scope of practice.

      Circumventing a policy — fine. Ignoring written doctor’s orders — not fine. There are gradations here — and it’s all about the regulated scope of practice for a doc, nurse, midwife, etc.

      Diagnosis and recommending a surgery is not part of an RNs scope of practice.

      Nor is underminign a doctor’s plan of care by planting doubts in a woman’s head. Example: asking a sick pg woman “do you really want to take those medications the doctor prescribed? What if it hurts the baby?” — I see this one at least one a month at the HER Foundation support forum.

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