Should Labor and Delivery Nurses Perform Moderate Sedation?

Carolyn Buppert, MSN, JD

Disclosures

October 16, 2017

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Should Obstetric Nurses Perform Moderate Sedation in This Scenario?

Response from Carolyn Buppert, MSN, JD
           Healthcare attorney

A registered nurse (RN) who works in the labor and delivery unit of a small hospital (approximately 550 deliveries per year) wrote to us with a question about RNs in her unit being required to learn how to perform moderate sedation:

Recently, we have been assigned moderate sedation training, and we were told that if we don't get checked off (eg, spending a shift at a pain management clinic and being certified as competent), we will no longer be eligible to work. The training is thorough, and I have no problem following the rules to become knowledgeable about something that has never been used in obstetrics before. The problem I have is the rationale for labor and delivery nurses being checked off as "competent in practicing moderate sedation." Our administrators say that we should be able to use this during an emergency cesarean section (C-section) performed under local anesthesia for severe fetal distress.

The problem is that this scenario is extremely rare. I believe it has happened three times in the past 10 years in our unit. Here are the factors involved in our situation:

  • We have anesthesia providers and operating room (OR) staff in house during normal business hours, so an emergency C-section during these times would be performed under general anesthesia. The scenario requiring emergency moderate sedation would occur during "off hours," when anesthesia providers for smaller hospitals are at home, on call. The standard is to arrive at hospital within 30 minutes of being called. So, the only time a C-section would ever be performed under local anesthesia would be when the obstetrician judges that the baby's life is in danger if not delivered immediately.

  • Labor and delivery nurses don't circulate or scrub for C-sections; the OR staff do that. We have a minimal "emergency" competence to open the OR and assist the obstetrician until the OR staff arrive. Many of our less experienced nurses have never done this, and the training is very minimal.

  • As a small unit, we typically have three or four nurses on nights and weekends, when this emergency scenario could potentially occur. The reality of any emergency situation with a baby in distress is that two nurses are needed to resuscitate the baby. No other nurses or staff in the hospital are certified in neonatal resuscitation. Pediatricians are at home, on call. An obstetrician doctor would need an assistant to perform the emergency C-section. With only three labor and delivery nurses on duty, that leaves no one to attend to the mother's sedation. We were told we could call the code blue team (an emergency department physician and other nurses who are competent in moderate sedation) to assist.

  • It is very clear in the guidelines for moderate sedation that there must be a provider immediately available to intubate if deep sedation occurs and the patient is not reversing as planned. We have been told that this would be the obstetrician—the same physician who is performing an emergency C-section under local anesthesia—until someone else arrives.

In researching the use of moderate sedation in obstetrics, I can't find any reference to it being used in the scenario of an emergency C-section under local anesthesia. In my view, it is ludicrous to expect that any labor and delivery nurse could devote complete attention to a patient as required by the regulations of moderate sedation. I don't see that the scenario is ever going to occur, and if it did, the plan presented to us isn't viable. My argument is that other people who practice moderate sedation regularly should be called in as soon as possible, but it is unsafe and unreasonable to expect the obstetric nurses to fulfill this role.

When I expressed these concerns to our administrators, I was told to do it or I would lose my job. I am concerned that having a meaningless check-off form declaring me competent in something that will never be used in my actual job could somehow put me in a situation in the future when I would be expected to use moderate sedation competently (for example, being pulled to another unit).

I have been an engaged, professional, educated (and competent!) RN for 31 years. I have been working in this hospital for 18 years and have generally loved my job. I hate for this to be the straw that breaks the proverbial camel's back, but that is how I am feeling now. Should we be required to learn and administer moderate sedation in this scenario?

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