-Nurses –
Keeping you out of the Courtroom
The birth of a baby can be the most joyous, memorable day in the lives of parents. Although they come into the world either by cesarean section or the more common vaginal delivery, either way an exhausted woman is typically synonymous with childbirth. This is a story of the lethal combination of an overtired postpartum mom and an un-attentive Nurse.
A 36 year old primigravida labored under epidural anesthesia over the course of a 12 hour night shift. Prior to going into spontaneous labor, she put in a full days work when her membranes ruptured. Arriving to Hospital at what would have been near the end of her workday, the primigravida was now in active labor. Everything progressed optimally and although an epidural was onboard effectively managing the pain, the labor remained as most women can relate-felt like a marathon. Adding to the elation of this event was the fact that her husband was the father of 3 sons from a previous relationship and today they were not only having their first child together, but a full term baby girl.
Baby girl delivered vaginally at 0645 with Apgars of 9&9. Both Mom and baby were stable and Phase 4 of the labor process commenced unremarkably. The Obstetrical Nurse proceeded with the usual duties following a delivery and baby was put to breast during this time. Shift change came at 0700 when the same Nurse said her congratulations and “goodbye” to the couple she cared for the past 12 hrs. They all looked forward to seeing each other “tonight on the postpartum ward” when the nights Nurse returned to work. The labor room was adjacent to the desk, where report was underway for the unit and day. During this 15 min turnover of staff, report was handed off to the oncoming day shift nurse who was made aware of the checks of the couplet required at 0715. Needless to say, all Nurses were abreast of the policy for both mom and baby checks following a delivery. Obstetrical Nurses are well acquainted with what these “checks” mean.
The nights Nurse departed, leaving an all so familiar scene of Nurses at the desk talking and getting started in their day. It is now 0725 and the call-bell goes off for the fresh postpartum patient. It is 10 mins past the required check, but the Nurse continues her conversation with her colleague who she’s not seen since their last rotation. Finally, at 0730 the Nurse enters the room to find the mom sleeping, dad semi-sleeping leaned up against the bed with his arms around his wife, new baby girl still at the breast and devastatingly dead. A full resuscitation was done with no success and all evidence that baby girl asphyxiated at the breast. Mom and dad say they called because baby looked like she was “just sleeping”.
What happened here? Were policies ignored that in fact were applicable to every patient? What’s a reasonable time to respond to the call of a patient in recovery but in particular a primigravida? Should the patient been left to breastfeed for the first time with only her husband?
Nurses don’t underestimate the importance of following policies. They’re there for a reason and whether or not you follow them can put you in or keep you out of a courtroom.
