December 7, 2010

Chart Review

Documentation on labor flowsheet (nurse documentation):
SROM @2:10 am, clear fluid, nitrazine positive . FHR 155,
reactive. Contractions every 5-10 minutes, (no change from prior entries). Mag Sulfate rate 2.5mg/hr.
3:25 am entry: EFM discontinued, patient taken to OR suite #1. FHR 150, reactive, contractions every 5-10 minutes, no vaginal bleeding. Mag Sulfate dc/d.

History & Physical:
IUP (intrauterine pregnancy) at 34 5/7 weeks, preterm labor. Gravida 5, Para 3, Prior c/s X 2. No response to terbutaline or procardia. Magnesium Sulfate protocol initiated.
PROM @ 34.5 weeks.

Progress note entry @ 3:30 am
Patient refused to go to OR until spouse present.

Hmm, sounds kind of silly to me to document on the patients chart that refusal. The patient is stable, baby is stable, doesn't appear anything changed after the patient water broke, and it is documented as such. Doesn't sound like such an unreasonable request of a patient in L&D to have her spouse present when she is delivered, since the baby was fine and there were no signs of uterine rupture. Especially since the time of SROM was only 1.5 hours prior to the time the patient was taken back for a c-section. I'm sure the patient would have consented to immediate surgery without her spouse should it have been necessary. I understand the need to document our backsides, but really? I've not seen this documented unless there was an issue that the baby wasn't tolerating labor or there were signs of a problem. Doesn't seem too necessary in this case.

This patient was very tearful, worried about a preterm delivery, hadn't wanted to deliver preterm. Not a case of tired of being pregnant. Not a patient who refused care just to refuse care. This was just a mom who wanted her husband there when their last child was delivered and really thought that her request to wait until her husband was present before going back for delivery wouldn't be a big deal. Her husband had been home, taking care of their other children and he was there in her room within about 1 hour. She would have consented to a c-section with no anesthesia, in the labor room, without her spouse, if it had been necessary.

I'm perfectly fine with that documentation on my chart. ;)

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