Hi all,

I am a registered nurse and a paramedic and I had a question about a patient I brought into labor and delivery from the field a couple of days ago. I am going to change the age around just to protect privacy.

The patient was a 28 year old women who called 911 after her "water broke"and she had presumably lost her mucous plug. Upon my arrival to the patient, she reports she is 22 weeks gestation, and is positive of gestational age because it was IVF. She is lying supine on the floor, reports a large gush of fluid after heading into the bathroom to have a BM, she and her husband were about to head to the hospital just prior too. She reports intermittent "cramping" all day with back pain as well, but does not know if it was contractions since she is G1 P0, I am assuming it was. She reports she is still having some intermittent "pressure" and light cramping a couple inches below her umbilicus, and assuming it was contractions I timed it with them lasting about 1 minute and they were 3 minutes apart. She was not presenting like someone in active labor however, and looked quite comfortable, and she denied any urge to push. She reports fetal movement yesterday, but does not remember if she felt any today because she said she was to preoccupied with the cramping. We obviously do not do internal lady partsl exams, but she was not crowning and there was no presenting cord or other parts. She had a small continuous flow of blood lady partslly throughout the transport. I did give her a liter of fluid wide open just in case she was abrupting and in a vein attempt to stop the contractions.

On arrival at labor and delivery the MD and RN met us at the bedside, they were able to get fetal heart tones which was in the 190s so obviously the baby was in significant distress. There was little to no amniotic fluid left per the MD, on bedside ultrasound. We obviously did not stay for the internal exam so I do not know how dilated she was.

My question is, is there any chance of keeping that baby in for another couple of weeks while providing mom with some steroids to increase lung development, or would the risk of infection be to high? Would they just monitor her for fever and try an keep the baby in or do they have to deliver or allow nature to take its course? Is that someone you would consider a candidate for magnesium or other medications to stop the contractions?

I know in some hospitals they would resuscitate a baby that age, but I asked what their policy was and they said they won't resuscitate unless the baby is at least 24 weeks gestation. They do have a level III NICU there.

Thanks for any information.

HPRN

Yikes, that's a tough one. Gestational ages that are right on the line like that make everyone kind of grit their teeth and pray.

I have had patients rupture earlier than this one but not admitted to hospital until 23 weeks, then stayed pregnant until 27-28 weeks and delivered.

Where I am it this pt would probably be admitted to try and buy her some time but they wouldn't do mag or steroids until 23-24 weeks (if she makes it that long) and they would not try to resuscitate until then either. There is a lot more info I'd want before saying for sure. Generally speaking, though, premature ROMs often stay pregnant for days/weeks until they either develop early sx infection, until they go into labor, or until they reach 34 weeks, whichever happens first.

Active labor in second trimester presents a lot differently than at term. What you are describing with the aches, cramps and pressure does sound like active labor to me, and I would be surprised if she was able to stay pregnant for another week, honestly.

Thank you guys for the info. I felt really bad since she and her husband had been trying for a long time to get pregnant and they finally do and this happens...

I told them I would cross my fingers and toes for them and their baby. I am hoping maybe they will be able to keep the baby in the oven for at least another 2 weeks, although I will never know, that is the hard part. She was receiving OB care at a hospital that does not have any NICU services which is why we diverted to this hospital, so at least if she is able to hold on for another two weeks and delivers a pre-term baby that is viable she will be in the right place.

I did talk to her about what she may expect, but my knowledge is limited since I have never and a patent present in such preterm labor, and she was understandably very upset and needed comforting. I did tell her it would depend heavily on the what the ultrasound and fetal heart tones showed and I would assume and exam by the physician and she understood that the information I could give her was limited.

I have never transported a patient in labor that is that premature so I had no idea what to expect as far as whether or not she was in active labor or not, so that was good information that this probably was active labor. I have delivered babies in the field a few times, including a set of twins, and they have all been full term, vertex presentation, easy stuff, and of course precipitous fast deliveries.

Keep the information coming if anyone has more to add. Thanks again.

HPRN