Surprise in Labor and Delivery – Part 2

March, 1982 – 12:50 a.m.

I glanced at the white board after we transferred the surprise twins to Neonatal ICU for observation (see Part I of previous post). Bonnie, the health tech, had put a new admission in my other room named Wanda. Bonnie handed me her blood pressure and temperature on a piece of paper, and warned me, “Pam, she is extremely overweight, so I think she will have a difficult delivery.” I walked in the room and introduced myself to Wanda who was accompanied by her equally large husband, Martin. She told me she was 23 years old and this was her second pregnancy. She had a miscarriage at 14 weeks last year. Her last weight in the office was 305 pounds. She said her contractions began about 5 hours ago and were now 5 minutes apart, so her doctor told her to come to the hospital to be checked. I had brought the doppler stethoscope with me which was a very sensitive electronic stethoscope that is more sensitive than the manual fetoscope.

Manual Fetoscope to listen to baby's heartbeat. Curved part is placed on nurse's head for conduction.

Manual Fetoscope to listen to baby’s heartbeat. Curved part is placed on nurse’s head for sound conduction.

Electronic doppler to listen to baby's heartbeat

Electronic doppler to listen to baby’s heartbeat

I placed ultrasound gel on the end of the doppler and began trying to listen to the baby’s heartbeat on her very obese abdomen for an entire 5 minutes. I couldn’t hear anything through the layers of fat. Wanda grimaced and said she was having a contraction as she looked at her focal point and started Lamaze breathing. I placed my hand on her abdomen to feel the contraction, but felt nothing. After she said the contraction ended, I did an internal exam and felt her tightly closed cervix with the baby’s head up high in the canal. I did not have an elastic band long enough to go around her abdomen for the external monitor, so  I asked her to walk around the halls with her husband for one hour and then I would recheck her. This was our standard procedure if we were unsure if the woman was in labor.

After an hour, I rechecked her and there was no change. I called the resident MD and gave him my assessment. “Give her one Seconal now and another to take at home if she is not asleep in one hour.” I went back in her room and told her that since her cervix had not changed in an hour, she was having false labor pains (Braxton Hicks) caused by her ligaments stretching and gave her the Seconal. She was NOT happy to be going home and told me so.

I finished that busy night, and as I was walking out the door at 7:30 a.m., Barb, one of the day shift nurses came up to me. “Pam, they just brought Wanda back up from the emergency room. The ER doctor delivered her baby in the parking lot! She is furious with you for sending her home and said she is going to sue you.” My heart sank and my eyes filled with tears as I walked out the door. Sometimes, nursing is a very tough job.

When I arrived home, I opened my Bible to Psalm 46 and asked God to comfort me.

God is our refuge and strength, a very present help in trouble. Therefore will not we fear, though the earth be removed, and though the mountains be carried into the midst of the sea…Be still and know that I am God; I will be exalted among the nations, I will be exalted in the earth. The Lord of hosts is with us; the God of Jacob is our refuge.

I prayed that Wanda and her baby would be healthy.

October, 1982 – 7:30 a.m.

After we gave report to the day shift, my head nurse came to me. “Pam, the hospital attorney wants to speak with you in the legal department at 8 a.m. about a law suit from one of your patients.” I took a deep breath and asked God to give me a quiet heart. I entered the office and a tall thin gray haired man greeted me and introduced himself as Attorney S.

“I asked you to come review a chart with me because a woman named Wanda S… is suing the hospital for emotional trauma, inaccurate assessment, and negligent care of her when she was in the labor and delivery unit. You were the only one who examined her,  and then she came back later that morning and delivered the baby in the parking lot. Please look at your charting and tell me about what you remember about Wanda.”

I opened her thin paper chart and read my brief notes. I read the verbal order I wrote from the resident to give her 2 Seconal capsules and discharge her home. Thankfully, he had cosigned it. It seemed strange to be reading my handwriting six months later. Attorney S said, “Did you forget to write any other assessment or do you remember anything else about what happened with Wanda that night?” “No, she was only there an hour. She was very difficult to assess because she was so obese. My charting is complete.” He thanked me for coming and I went home.

I never heard the outcome of the law suit. It was a good reminder to me to chart completely and accurately immediately as things occur, especially in a place like labor and delivery where things change dramatically in mere seconds.

Reflection

One of the huge problems in medical care in the USA is the cost which is driven up by exorbitant malpractice suits against medical professionals. When I took a nursing tour of China in 1986, I was amazed that each patient only had a single piece of paper on a clipboard hanging on the end of their bed. I looked with longing at that little clipboard, wondering what it would be like to only have to write a few characters on each patient each shift. The head nurse explained that since it is a communist nation, the people were not permitted to sue any doctor or nurse for malpractice. Each patient has their personal health notebook that they bring to the clinic or hospital and then take back home. Therefore, there are no departments for medical records or malpractice attorneys.

Minimal charting in China in 1986

Minimal charting in China in 1986

Much of the charting we do is to prove we are practicing nursing according to the standard of care and to cover ourselves if we are ever sued. My college nursing instructor drilled into us, “If it’s not charted, it’s not done.”

The following is an exerpt from “Make Your Nursing Care Malpractice Proof” – January 2012, Vol 7, No. 1 by Deanna L. Reising PhD, RN

Six categories of nursing malpractice claims have been identified:
•failure to follow standards of care
•failure to use equipment in a responsible manner
•failure to assess and monitor
•failure to communicate
•failure to document
•failure to act as a patient advocate or follow the chain of command.

As I thought about the situation with Wanda, thankfully I did not commit any of those “failures.” Babies simply have a mind of their own, and they don’t read a book about how or when to be born. Expect the unexpected in obstetrics.

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Transcultural Nursing Course – Dominican Republic – Part 3

Transcultural Nursing Course – Dominican Republic – Part 3

January 3, 1995

It seems hard to believe that our trip is half over. Today, we returned to the city hospital to work as a group so Tammy could translate for us. We made rounds in the pediatric ward and watched a skilled nurse easily start several IV’s in babies, unlike yesterday. She wore a cap with a blue velvet band, so she has a Bachelor’s degree in nursing.

Then we went to the Labor and Delivery unit. When the nurses learned I had experience in labor and delivery, they assigned us to a 28 year old woman having her fourth baby who had just been admitted. The doctor examined her and said she was half way dilated and broke her water. We went on rounds and I checked her before lunch. No change. We felt her contractions and I tried to listen to the baby’s heart beat with my new stethoscope, but couldn’t hear anything. There is no fetal monitoring available here.  She looked very comfortable, so we had a leisurely lunch. When we returned at 2 p.m., she was writhing in bed in pain and looked like she was in the transition stage. I asked for a sterile glove, checked her, and she was totally dilated. I asked her to push and the baby’s head crowned, so I told her to blow so she wouldn’t have the baby in bed.  The Dominican nurse said it was time for her to go to the delivery room. We watched in amazement as the mother stood up, and walked in her sandals to the room, laid on the table, and put her feet in the stirrups.

The nurse then told me that they do all the normal deliveries rather than the physician, and motioned me to deliver the baby! It has been 13 years since I worked in labor and delivery, so I silently prayed, Dear Lord, help me! Bring this new baby into the world safely. Amen. The mother gave two pushes and the baby came out with a cord around his neck once which the Dominican nurse quickly removed so he wouldn’t strangle. The baby boy then let out a loud scream, and we all breathed a sigh of relief. It was so exciting! Then the nurse put two clamps on his cord, cut it, and motioned me to carry him to the bassinette. I rubbed him down and gave him an Apgar score of 8 at 1 minute, and 9 at 5 minutes which is totally normal. Thank you, Lord.

The nurse gave me a sterile string and motioned me to tie the cord closer to his abdomen, so I tied my best Girl Scout square knot, and asked if I did it right? She said, “Si!” (yes). Then Julie cut the cord again between the clamp and the string. They removed the 2 clamps so they could sterilize them and reuse them. We examined the cord, and it had three vessels which was normal. Julie and Paula then delivered the placenta. I handed the baby to Mom and she began to breastfeed him. After the nurse cleaned Mom, she stood up and walked to the wheelchair, and was wheeled down the hall to the postpartum area. Mom never screamed the whole time, but only grimaced. She made childbirth look so incredibly easy.

After we settled Mom in bed, she thanked us profusely, while hugging and kissing each of us.  It was so gratifying. The other students had never participated in a delivery before, so we were all thrilled. The miracle of birth never ceases to amaze me. God is so magnificent!

Lo, children are an heritage from the Lord; and the fruit of the womb is His reward. Psalm 127:3

Holding the new baby after I delivered it!

Holding the new baby after I delivered it!

Mom brought two disposable diapers with her. I saw a price tag of 3 pesos on one which equals 25 cents in the US. This is lots of money for her.  Each patient is only given one bed sheet their entire stay.

We then made rounds on the rest of the hospital. The men’s ward had 20 beds with quite a few men in traction from femur fractures from motor scooter accidents. We then went back to the ICU. The three patients we saw yesterday are about the same. The lady with high blood pressure actually had a stroke rather than a blood clot in her lung. Her right pupil was enlarged and non reactive to light. Her left arm was limp, but she could move her left leg. I checked her blood pressure, and it was back up to 196/110 and her heart rate was only 56. There was a new lady who was there with an asthma attack and was on oxygen. They had the head of her bed propped up with a chair since there is still no electricity today.

Through Tammy’s interpretation, I found out more about, Martha, the ICU nurse. She works 9 days out of 14 with two days in a row on each shift, and then she gets two days off. Dr. Elaine said nurses and doctors are not respected in the Dominican culture and the pay is very low. The head nurse makes the equivalent of $120 per month in U.S. dollars.

We then met with a lady in charge of infant feeding who has a doctorate degree from Santo Domingo. She showed us their beautiful classroom with a TV and video player. Mothers complete an 18 hour course of nine two hour classes on infant care. They have posters all over the hospital forbidding baby bottles and other posters showing a beautiful dark haired Mom breastfeeding her baby. This hospital has 190 beds for the whole region, which is not enough. They had 4000 births in 1993, and 6000 births in 1994.

At the end of the day, I rode back to the clinic Dominican style taxi, on the back of a motor scooter, hanging on to the driver for dear life and asking the Lord for safety the whole way. Then I paid him the going rate of 3 pesos – 25 cents. What a day!

Dear Lord, Thank you for the safe delivery. I pray this new baby boy and his Mom will receive you as personal Savior. Thank You for all You have taught me today and for the strength and health You have blessed me with. In Christ’s Name, Amen

 

 

Surprise in Labor and Delivery – Part 2

March, 1982 – 12:50 a.m.

I glanced at the white board after we transferred the surprise twins to Neonatal ICU for observation (see Part I of previous post). Bonnie, the health tech, had put a new admission in my other room named Wanda. Bonnie handed me her blood pressure and temperature on a piece of paper, and warned me, “Pam, she is extremely overweight, so I think she will have a difficult delivery.” I walked in the room and introduced myself to Wanda who was accompanied by her equally large husband, Martin. She told me she was 23 years old and this was her second pregnancy. She had a miscarriage at 14 weeks last year. Her last weight in the office was 305 pounds. She said her contractions began about 5 hours ago and were now 5 minutes apart, so her doctor told her to come to the hospital to be checked. I had brought the doppler stethoscope with me which was a very sensitive electronic stethoscope that is more sensitive than the manual fetoscope.

Manual Fetoscope to listen to baby's heartbeat. Curved part is placed on nurse's head for conduction.

Manual Fetoscope to listen to baby’s heartbeat. Curved part is placed on nurse’s head for sound conduction.

Electronic doppler to listen to baby's heartbeat

Electronic doppler to listen to baby’s heartbeat

I placed ultrasound gel on the end of the doppler and began trying to listen to the baby’s heartbeat on her very obese abdomen for an entire 5 minutes. I couldn’t hear anything through the layers of fat. Wanda grimaced and said she was having a contraction as she looked at her focal point and started Lamaze breathing. I placed my hand on her abdomen to feel the contraction, but felt nothing. After she said the contraction ended, I did an internal exam and felt her tightly closed cervix with the baby’s head up high in the canal. I did not have an elastic band long enough to go around her abdomen for the external monitor, so  I asked her and her husband to get up and walk around the halls for 60 minutes and then I would recheck her. This was our standard procedure if we were unsure if the woman was in labor.

After an hour, I rechecked her and there was no change. I called the resident MD and gave him my assessment. “Give her one seconal now and another to take at home if she is not asleep in one hour.” I went back in her room and told her that since her cervix had not changed in an hour, she was having false labor pains (Braxton Hicks) of her ligaments stretching and gave her the seconal. She was NOT happy to be going home and told me so.

I finished that busy night, and as I was walking out the door at 7:30 a.m., Barb, one of the day shift nurses came up to me. “Pam, they just brought Wanda back up from the emergency room. The ER doctor delivered her baby in the parking lot! She is furious with you for sending her home and said she is going to sue you.” My heart sank and my eyes filled with tears as I walked out the door. Sometimes, nursing is a very tough job….

When I arrived home, I opened my Bible to Psalm 46 and asked God to comfort me.

God is our refuge and strength, a very present help in trouble. Therefore will not we fear, though the earth be removed, and though the mountains be carried into the midst of the sea…Be still and know that I am God; I will be exalted among the nations, I will be exalted in the earth. The Lord of hosts is with us; the God of Jacob is our refuge.

I prayed that Wanda and her baby would be healthy.

October, 1982 – 7:30 a.m.

After we gave day shift report, my head nurse came to me. “Pam, the hospital attorney wants to speak with you in the legal department at 8 a.m. about a law suit from one of your patients.” I took a deep breath and asked God to give me a quiet heart. I entered the office and a tall thin gray haired man greeted me and introduced himself as Attorney Steel.

“I asked you to come review a chart with me because a woman named Wanda S is sueing the hospital for emotional trauma, inaccurate assessment, and negligent care of her when she was in the labor and delivery unit. You were the only one who examined her,  and then she came back later that morning and delivered the baby in the parking lot. Please look at your charting and tell me about what you remember about Wanda.”

I opened her thin paper chart and read my brief notes. I read the verbal order I wrote from the resident to give her 2 seconal and discharge her home. Thankfully, he had cosigned it. It seemed strange to be reading my handwriting six months later. Attorney Steel said, “Did you forget to write any other assessment or do you remember anything else about what happened with Wanda that night?” “No, she was only there an hour. She was very difficult to assess because she was so obese. My charting is complete.” He thanked me for coming and I went home.

I never heard the outcome of the law suit. But it was a good reminder to me to chart completely and accurately immediately as things occur, especially in a place like labor and delivery where things change dramatically in mere seconds.

Reflection – 2015

One of the huge problems in medical care in the USA is the cost which is driven up by exorbitant malpractice suits against medical professionals. When I took a nursing tour of China in 1986, I was amazed that each patient only had a single piece of paper on a clipboard hanging on the end of their bed! I looked with longing at that little clipboard, wondering what it would be like to only have to write a few characters on each patient each shift. The head nurse explained that since it is a communist nation, the people were not permitted to sue any doctor or nurse for malpractice. Each patient has their personal health notebook that they bring to the clinic or hospital and then take back home. Therefore, there are no departments for medical records or malpractice attorneys.

Minimal charting in China in 1986

Minimal charting in China in 1986

Much of the charting we do is to prove we are practicing nursing according to the standard of care and to cover ourselves if we are ever sued. My college nursing instructor drilled into us, “If it’s not charted, it’s not done.”

The following is an exerpt from “Make Your Nursing Care Malpractice Proof” – January 2012, Vol 7, No. 1 by Deanna L. Reising PhD, RN

Six categories of nursing malpractice claims have been identified:
•failure to follow standards of care
•failure to use equipment in a responsible manner
•failure to assess and monitor
•failure to communicate
•failure to document
•failure to act as a patient advocate or follow the chain of command.

As I thought about the situation with Wanda, thankfully I did not commit any of those “failures.” Babies simply have a mind of their own, and they don’t read a book about how or when to be born! Expect the unexpected in obstetrics.

All About Babies!

Labor & Delivery Nurse – Midwest USA, August, 1981

I have begun my orientation in Labor and Delivery which is 6 weeks on day shift and 2 weeks on night shift. This 1000 bed private hospital in the suburbs of the city seems much more professional and more advanced than the inner city hospital where I worked the past 4 years. I have had many individual classes taught by the various nurses, watched videos, and read medical journals and books about normal labor and delivery, high risk deliveries, and emergencies. They alternate classes with having me work with a different nurse preceptor weekly. Each nurse has a different teaching style and level of experience, so it has been a very thorough orientation for which I am thankful.

Some days, it is a bit overwhelming trying to absorb and remember all this new information. Every day I pray and ask God to teach me and give me wisdom in every situation. God has been encouraging me through these Bible verses:

“Not that we are sufficient of ourselves to think anything as of ourselves, but out sufficiency is of God.” 2 Corinthians 3:5

“I can do ALL things through Christ, who stengthens me. Philippians 4:13

“For the Lord gives wisdom.” Proverbs 2:6

I now understand why they never hire new graduates to work in labor and delivery. My background in medical-surgical nursing is certainly helpful when making split second decisions. Probably the biggest adjustment is taking care of two people at once (mother and baby) but only being able to see one of them until the baby is born.

fetal monitor2

External Monitoring of Baby’s Heart and Uterine Contractions

I passed my course in learning to read fetal monitor strips. I assess my assigned mother every 15 minutes and write my initials and all medications I give her on the paper of the fetal monitor strip. Each baby’s heart rate and the uterine contraction is transmitted electronically to the bank of 10 monitors at the nurse’s station. One of the technicians is assigned to sit and watch the monitors at all times. If they notice a baby in trouble, they immediately notify the assigned nurse. They rotate the techs during the shift since it is difficult to concentrate on the screens for more than an hour.

I am learning so many new skills such as applying the internal fetal monitor lead to the baby’s skull, and inserting the intrauterine catheter that measures the strength of the contractions. The internal exams are the most difficult to learn where I assess the stage of labor. With 2 fingers I feel how far the cervix is open (dilated), how thin it is (effaced), how far the baby’s head has descended. I check the mother first and then the experienced nurse rechecks to see if I’m correct. We go out in the hallway and I tell my preceptor my findings and she tells me hers so I can see if I’m correct. We only ask experienced mothers who don’t seem to mind double exams to help teach a new nurse like me.

After my assessment, I go out to the nurse’s station and write the findings on the 8 foot by 10 foot white board with an erasable marker. Beside each mother’s name is her doctor’s name, nurse’s name, her age, number of pregnancies she has had, time, and exam results. This way anyone can glance at the board and see how many patients we have in labor and what stage they are in. We all constantly help each other and are in and out of many mother’s rooms each shift. We all dread the days when all 10 rooms are filled! That means the next woman in labor has to go in the hallway on a stretcher. Thankfully, that doesn’t happen often! The most deliveries they have had in 24 hours in 28! They have 4000 births here annually.

I have learned how to circulate in a Caesarian section surgery, vaginal delivery, do Apgar scores of the baby at 1 minute and 5 minutes of birth, give pitocin to make the uterus contract harder, give intravenous pain medications, treat preeclampsia when the mother’s blood pressure goes dangerously high, and treat premature labor. I have not participated in an emergency C-section yet…

I have also worked in the recovery room where the mother stays for one hour after delivery. In the birthing rooms, the mother labors, delivers, and recovers all in the same room so I really get to practice all my new skills there. Every evening when I go home, I am so exhausted from so much new information! But next week I get to go back on night shift for the final two weeks of orientation. I think it will be fine once I become more sure of my assessment skills and get in a routine so I don’t have to think so hard about every little thing. Nothing is automatic yet like it was in  medical-surgical nursing. It’s rather unsettling to go from an expert level in diabetes back to a novice nurse in labor and delivery. But I know over time I will become comfortable in this setting like I did in diabetes and medical-surgical nursing.

Reflection – 2014

Over the years, the Lord has allowed me to work in a variety of areas of nursing. Sometimes I have had an excellent orientation and other times it has been “sink or swim” which is extremely stressful. My transition into labor and delivery was very thorough, but still stressful. It is always difficult to go from the expert level back to the novice level when you switch areas. That is probably one reason the labor and delivery nurses seldom left once they found their niche in nursing. Plus, most of them seemed to really enjoy it as did I. But it was probably the most physically demanding nursing I have ever done as I will describe in future posts. It took a huge toll on my body and health.

On the other hand, one of the joys of nursing is having the option of switching specialty areas for those who become easily bored like me!