27 Oct At the change of shift, an experienced nurse came on duty in the birth center in a community teaching hospital and took over the care of a woman who was in active labor with an oxytocin infusion and an epidural in place.

At the change of shift, an experienced nurse came on duty in the birth center in a community

teaching hospital and took over the care of a woman who was in active labor with an oxytocin

infusion and an epidural in place. The woman was admitted the evening before for induction of

labor with no risk factors, normal vital signs, and a normal fetal heart rate tracing. On initial

assessment the nurse noted the mother’s heart rate in was 110 (up from a baseline of 70) and the

fetal heart rate baseline was 165 (up from a baseline of 140) with minimal variability and

recurrent late decelerations. The woman was not febrile, but complained she did not feel well.

Concerned about the maternal and fetal heart rate indicators and maternal complaint of not

feeling well, the nurse requested a bedside evaluation by the attending obstetrician. The

attending obstetrician evaluated the patient, who had progressed to the second stage of labor. No

management changes were proposed, and the attending obstetrician planned to return in one hour

to check on the woman’s condition. At that time the nurse thought an hour was too long to

“watch and wait,” but trusted the attending physician’s expertise and agreed to the plan without

voicing this misgiving.

The nurse stayed at the bedside to monitor maternal-fetal status closely, and administered fluids,

positioned the woman laterally, encouraged rest and pushing with every-other contraction, and

applied oxygen.

During this time, the charge nurse was managing a full unit with several urgent patient care

demands occurring simultaneously. The charge nurse periodically checked the fetal heart rate

tracing on the central monitor over the next 30 minutes and noted the tracing was worsening, but

also trusted the expertise of the nurse and attending physician working with this patient. The

charge nurse was confident the situation would be handled appropriately.

After closely monitoring maternal-fetal condition over the next 30 minutes, the nurse called for a

reevaluation. Fetal heart rate variability was minimal to absent and the decelerations were

deepening. The attending obstetrician came in and the team (now including a resident physician)

agreed to move to the operating room and attempt an assisted vaginal birth. As the team moved

the patient to the operating room (OR), the attending physician left the unit briefly and the team

was not aware of this. In the OR the nurse was thinking about how much time they had to get the

baby born, noting further deterioration of the fetal heart rate tracing with increasing urgency. She

was concerned that the resident was consenting the patient in a non-urgent fashion and the

attending physician was not present to supervise the birth. She said, “We’ve got to MOVE [get

this baby born] now!”

The charge nurse entered the operating room and immediately paged the attending obstetrician,

who came in and took over the birth. The infant was born vaginally with forceps and had

evidence of metabolic acidosis. In a retrospective review, both nurses identified a point on the

fetal monitor tracing where the heart rate became very worrisome and called for intervention

almost an hour prior to the time of the birth.

 so on this paper what are the Alternatives and Recommended Solution?