Hide the Vacuum
Posted by realityrounds on November 23, 2009
Have any of you ever played “Hide the Vacuum?” No, I am not talking about hiding a household appliance because you do not feel like doing housework. I am talking about “hiding” the vacuum extractor during a childbirth. Apparently it is a very fun game.
I never got to play this game (kinda like being picked last during kick ball in grammar school…. meanies), but many popular, seasoned L&D nurses have told me about it. The rules of the game are such:
1. Mom is pushing great, but with much effort, and the clock is ticking.
2. Coach calls an audible….the vacuum extractor, now!
3. Player thinks, bad call!, but must comply. “OK, let me get you that vacuum. Oh my, where is it? It is not in the procedure cart, it is not on the delivery table, let me check the storeroom. Keep pushing mom, while I look.”
4. Player walks very slowly down hall to storeroom to buy time. Praying all the way that momma pushes out baby in the meantime.
5. Player walks slowly back to room with vacuum in hand, and mom has miraculously pushed baby out herself without a suction cup being placed a top her baby’s head (or, mom did not push baby out, and was yanked out by a vacuum extractor..game over).
I am glad that I am a NICU nurse and do not have to play the “hide the vacuum game.” There have been many articles written about the “Doctor-Nurse Game” where nurses are passive-aggressive when it comes to conflicts they feel about the care of a patient. Instead of coming right out and saying, “I do not agree with X and Y because of Z, they twist their thoughts and words to make it seem as if the physician thought of the idea themselves. “Well doctor, I saw you once do W, that was great, and why don’t we try W again, instead of doing X and Y…blah, blah, blah.” Hiding the vacuum is another sort of desperate passive aggressive game that a nurse may play to save the patient the trauma of a vacuum birth. In the heat of the moment it can be very difficult to tell a physician to hold off on the vacuum while he/she is sitting at the perineum. So, a nurse may choose to just “play to game,” and “hide” that vacuum or play ignorant as to where that equipment is in hopes that the mom will, in the mean time, deliver the baby without the help of an “instrument.”
No matter what the context in medicine the Doctor/Nurse game is a sad and antiquated game that needs to stop. It is demeaning to the nurse, doctor (most doctors like team-work), and it can be dangerous for the patient. One of the reasons I love NICU nursing so much, is that I have always felt a peer to the neonatologist and pediatricians that I worked with. It really feels like team effort. I often do not see this type of collaboration in OB, and it makes me sad.
Let’s stop playing games.
RR
atyourcervix said
We have no excuse to play that game. We have vacuums (2!) in every birthing room. I will, however, get passive aggressive with a certain doc who insists on stirrups at every birth. “gee doc, I don’t know how to set those up.” I’ve called him on it too – not in front of a patient. Asked him why he insists on stirrups at every birth — he said it was because “her legs are too heavy – how are you going to hold her legs up for the birth and do your job too?” Well gee, I do it every day. It usually involves having the spectators (ahem, support people) hold the legs while I’m “doing my job”.
Labor and delivery RN said
Our “game” is fudging about dilitation. Many of our docs don’t believe in “sliding” and prefer that moms start pushing as soon as they are complete, even without the urge. So they are “stuck” at 9 cm or an anterior lip for a couple of hours. And, like At Your Cervix, we have 2 or 3 Kiwis in every room.
lpnmon said
And this is why I don’t want to do L&D. Blech. While there are a few docs and nurses who play these games on the med/surg unit where I work, for the most part we all work together.
So how do you get it to stop? How do you convince docs of the nurses’ concerns? Has anyone worked on a unit that doesn’t have those games? How?
-lpnmon
KM said
I’m not a nurse, I’m a mother,and I can say that I would be greatful for this game, no matter how passive aggressive, to buy me some time if the doctor was getting impatient.
I’m not sure how this is any more “dangerous” than an actual vacuum extraction can be, not to mention traumatizing.
During the birth of my second child I was feeling the urge to push, but my OB insisted that I was only at 8, and maybe I should get in the tub. She was a great OB, but she wasn’t listening to me, as so many often don’t. My nurse, after listening to me insist for 10 minutes that I was ready to push and wasn’t going anywhere, suggested that maybe the doctor try to see if she could push the lip of the cervix back a bit. Low and behold, I’m a full blown 10 and crowning. Baby was born 2 pushes later.
I am SO thankful to my L&D nurse for that. It wasn’t passive aggressive, and thankfully I had an OB that listened to her, but maybe if our OB’s listened(and SAW) their patients more, it wouldn’t put the nurses in between them.
THANKYOU L&D!
Jerry McLaughlin said
As an Ob doc, I’m glad to see this discussed openly, but sad that the situation exists. Communication is critical between members of the Ob/L&D team, and should occur regularly and prospectively. Suggestions like reducing the lip should always be welcome and open disagreements in front of the patient should NEVER occur.
If nurses have concerns about vacuum use (overuse?) with a particular doctor, an easy, but still passive-aggressive, way to deal with it is to include discussion of it in signing the delivery consent. If the patient expresses reluctance to have it used, pass that on to the doc who then bears the onus of discussing it further. “Hide the vacuum” just makes L&D staff look less competent & is a real problem if a poor outcome occurs.
realityrounds said
Jerry,
Thanks for your input. I also agree that any sort of passive-aggressive nurse/doctor communications should stop. One of the major causes of medical errors is communication breakdowns. I do not work L&D, so this was an anecdotal post about some comments L&D nurses have told me. Did it really happen or was what they were telling me tongue in cheek? I do not really know. The post was more about open communication for what is best for the patient. As you know, doctors and nurses often have differing opinions on this. It can really be hard (impossible) to discuss these outside the patient room while she is crowning.
Thanks for commenting, and I hope you will continue to in the future!
J said
RR,
The sad thing is, it probably really did happen. While I’ve never had to play “hide the vacuum” – we don’t use them that often, I have used similar tricks as an L & D nurse – many of us have. As someone earlier said, a lot of us have “fudged” dilation. “Oh, she’s only 8 cm, let’s sit her straight up and let that baby come down,” if you know the doc won’t let her labor down. And when the lidocaine was no longer automatically on the delivery table, I always forgot to grab it from the sure med – until I discovered that calling out for it bought me enough time that the episiotomy couldn’t be done. Then I would “forget” to grab the lidociane for certain docs known to cut them on everyone.
Yes, there are certain docs that I could openly make some suggestions to – like “how about we try pushing this way”. But questioning bigger things like episiotomies, c-sections, etc, would probably get me in major trouble with the docs, and I would probably actually fear for my job. And I’m not sure it would actually change how they practice. If your still laying patients flat to push, and cutting an episiotomy on every patient, are you really going to listen to what a nurse has to suggest – even if she has research to back her?
J
Joy said
That sounds really childish. Whatever happened to communication? Do nurses really feel so inferior that they cannot speak up? They cannot offer insight and wisdom and even facts to a doctor about the misuse of a vacuum extractor?
Aron said
No, nurses do not feel “so inferior” that they can’t speak up. It is rather the other way around: doctors with such a massive superiority complex that they can’t tolerate rational input from a lowly nurse no matter how much the evidence is on her side. When the nurse’s job is on the line she’s perhaps a bit less prone to be overtly confrontational.
Erin said
Amen, Aron!
RR, I wish that our NICU had such great relationships between RNs and MDs… unfortunately, I think that many times we have to resort to making it look like they came up with the idea that we prefer.
Amy said
Here’s a story that backs up hiding that vacuum —
there was a practice of Midwives in our area with great outcomes. They joined a practice of doctors for financial reasons. Their use of the Vacuum/forceps was rare up until that point. once they joined with the doctors almost everyone of their patients suddenly “needed” Vacuum extraction. It caused serious permanent damage to several women.
within a year the midwives separated their practice from the doctors. as soon as this occurred the vacuum use rate went back down to where it was before, and lo and behold, babies were born anyway, but with much less trauma.
I am very appreciative of all of the labor nurses who put thier patients first!
Kristie said
I don’t think I’d be very grateful if the nurse took a little too long, and my baby took a sudden turn for the worse. This is ridiculous.
Cath Young said
I don’t think it is up to the nurse to play “hide the vacuum” or other such games. The doctor is the boss in this situation. There is a reason for that, namely the years of education and depth thereof.
If a nurse finds that a doctor is truly incompetent or sloppy, it’s time to find another job. Fortunately with the nurse shortage, it can be done unlike in many other professions where it cannot be as easily done.
Nicholas Fogelson said
Nobody should be playing “hide the vacuum”. Its unprofessional and ridiculous. We can all discuss the merits and problems with operative vaginal delivery, but to address the issue with childish games is unprofessional and downright dangerous. Anyone can claim that some doctor has a superiority complex, but in the end they are the ones that are ultimately responsible for the patient’s outcome.
Medical decision making is hard. There are a million things going through my mind when I am deciding whether or not to do an operative vaginal delivery. If there is some piece of information I am missing, I am appreciative of a nurse who lets me know that piece of information. I am not, however, appreciative of a nurse who tries to influence this decision based on what they think about operative vaginal deliveries in general. I am more than happy to discuss the issue in general with anybody that wants to, but it is not helpful to have to defend one’s decisions to the patient’s nurse because they happen to disagree.
Nicholas Fogelson MD
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