[redhedgoddess]

Warning: I'm venting about a fetal demise, my first, of a full-term, beautiful baby girl. Here goes the story...

Had a pt admitted to the hospital at 35+ weeks gestation for diabetic teaching and management of gestational diabetes, usual workup: NST, BPP c EFW... Neither she nor her husband speak English. G3P2. According to prenatal, had rec'd diabetic couseling as outpt since diagnosis with repeated notations of non-compliance with diet, refusal of insulin. I was her nurse that day. She showed up 6 hours late and, even though MD had told her to be prepared to spend at least 24 hours, up to 5 days as inpatient, had brought her two children and husband with her. She had never planned on staying even overnite, lied about her blood sugars, dietary intake... everything. She did have a reactive NST and 8/8 BPP. I heard the MD telling her that if she continued as she had been, the baby could very well die. She obviously didn't believe him. After the MD left, she was ready to walk out AMA. I, through a translator, asked her if she was prepared to trade her daughter's life for the inconvenience of staying for a few days in the hospital? She stayed overnite but walked out early the next a.m. before the MD returned.

Our hospital has started admitting scheduled C/S straight to pre-op holding (I won't even go into how we feel about that) and the OB nurse goes down, does FHTs by doppler just prior to delivery. She was sceduled for PC/S for breech presentation 37 wks gestation. So... down I go to pre-op with my trusty little doppler... can't find the tones... go get the MD... no tones... When was the last time she felt the baby move? "This morning." He asked her 4 times, in front of me, when she last felt the baby move... all 4 answers: "This morning." Stat US... dead baby. The decision is made to deliver by C/S. Out comes a beautiful, perfect baby girl, 9-10, no cord, no visible anomalies, not recently dead. The last NST c BPP had been a week before, reactive and 8/8. The MD had tears in his eyes and closeted himself in the dictation room for awhile by himself.

When she came up to the unit, I was passing in the hall. We made eye contact, briefly. I touched her arm, said "I'm sorry." She started sobbing. Daddy held his dead daughter briefly, Mom refused. I collected a lock of hair, took pictures and put together a bereavement package for the family. I don't know that I'll ever forget that baby's face.

I have mixed feelings toward the parents. They definitley were made aware of the risks of gestational diabetes and the possible outcomes. I'm angry that she could blithely lie, while looking so earnest, about her compliance with treatment. I'm sorry that they lost their daughter. I'm so very sorry that a baby girl died because Mom and Dad couldn't be convinced of their responsibility to their unborn child.

I think I'm done venting. Thanks for reading. Thoughts are welcome.

[wanna B an RN]

this is just awful! I'll bet that the mom thought that everything would turn out ok. I myself had twin babies that were 6 weeks early and I am very thankful that they turned out perfect. I must confess though, that I didn't follow the bed rest orders very well. I could give all sorts of excuses, but why bother, luckily they turned out ok. I'm wondering why the mother felt the need to lie though.

[LDRN697]

What a terrible and hard lesson these parents had to learn

[P_RN]

I haven't cried in quite a while. Until now. This is so sad, for the parents and for you.

P

[dawngloves]

Non compliance and denial drives me crazy!! This has got to be the epitomy of it.

[rdhdnrs]

Demises, especially full-term, are always devastating to all concerned. It is especially hard on the nurse or doc who actually discovers the absence of heart tones.
One thing to keep in mind in your case is the culture difference. At the university hospital where I work, we take care of many Hispanic patients, and there is a lot of "non-compliance" with regimens such as for diabetes, etc. We must be careful to be non-judgemental and realize that in other cultures health issues are approached quite differently. Also the fact that this mom didn't speak English may have played into the problem.

I am so sorry you had to go through this. Even though it's part of what we do, it creates a wound, doesn't it? You can always vent to us other nurses. I really believe we're the only ones who can truly identify.

One other thought: When this kind of thing happens at work, I hope you take extra good care of yourself afterwards. You deserve it.

Lisa

[motorcycle mama]

As a mother of four (heck, even if I wasn't a mother) this makes me sick.
Unfortunately, it takes something drastic to make believers out of some people.

[LizzyL&DRN]

I'm sorry RedHead you had to deal with this. Unfortunately it's part of this field, and when our field is sad, it is sooooo sad. I too just had my first full term fetal demise a couple weeks ago. Mom had done everything right. All her prenatal visits, watched her weight, took all her vitamins. She came in and thought she was in labor, and we couldn't find heart tones. She delivered a 9lb 9oz baby that had been gone at least 2 days. It was a very difficult delivery. We all have to find a way to deal with the emotions of these deliveries. It makes it worse when we think it was preventable. Take care of yourself....

[PegRNBSN]

Some things to consider,: Staying in the hospital may have been more than an inconvenience to this mom. I have had moms leave AMA from our antepartum unit because they had no one to watch their other kids and husband's job was in jeopardy because of missing work.
Did this woman read? What was her educational level? Sometimes these play a part in patient compliance.

[Elvish]

Fetal demises don't ever get any easier. Every single one that you are a part of rips some part of your heart out. So my heart goes out to you in a big, big way.

Please be aware, as some other folks have mentioned, that there is a 100% chance of there being cultural factors behind this situation. I didn't pick up from reading this where these patients were from, but if they were Hispanic, there are a lot of things about Hispanic culture that would explain some of this. I used to work in a community health center that served primarily Hispanics; I did diabetic education and there was A LOT that I learned from that. I've also been a part of the Hispanic community in our area x 7years. I don't know anything but what you've told us in your post, but maybe this will shed some light...

Sometimes what you & I see as non-compliance is really an inability to choose for themselves what they eat. Sometimes they live in a house where they are told what to prepare & eat. Their husbands or other men in the house are seen as the head of the household and these women will defer to their wishes. Even if it means harm to themselves. Sometimes diabetic diet teaching -- and I have been guilty of it myself -- is not geared toward Hispanic diet, or is not done in a way that is culturally relevant to Hispanics. I don't know anything about what sort of teaching she received, so I'm not making a judgement on that. Just throwing some ideas out there.

Hesitancy to go on insulin or outright refusal of it is extremely common among Hispanics, though I've heard of it happening in other cultures too. What I used to hear is "I don't want to go on insulin because my [aunt, brother, mother, whatever] went on it and died not too long after." It's hard to explain that the insulin didn't cause the death, the advanced diabetes did.

Hispanics tend to have a very different idea of time than non-Hispanics. 6 hours late is not unheard of, for anything. A Hispanic friend of mine's sister got married, supposedly the ceremony was starting at 2:30pm. Around 4pm, the bridesmaids showed up at church to start ironing the dresses. About 6:30 the ceremony started. What was really funny is that the white guests were there at 2:15. Most of the Hispanic guests didn't arrive til after 5:30. Punctuality is not a high priority, and time is seen as much less concrete. It drives me crazy too, and my personal feeling (on the time issue, at least), is that thing about when in Rome...But that might explain why she got there late. Or maybe there's only one car, and the husband had to get home from work before they could get to the hospital. Maybe they had no one to watch the kids. Again, I don't know. I'm just throwing out ideas.

I have also had many many many Hispanic patients that refused to believe that anything was wrong with them (talking about diabetes, HTN, bad Paps, many things) because they didn't feel bad. That's a very cultural thing. The severity of the illness is often viewed as directly r/t how it interferes with your daily function. So if she wasn't complying with her diet etc., it may also have been because she didn't feel bad. And if she didn't feel bad, she perhaps saw no reason to stay in the hospital.

I am not entirely surprised that she did not want to hold the baby. Not everybody deals with their grief that way. I personally would want to, but I have had many moms of all backgrounds say they don't want to hold their dead babies.

I completely understand your frustration and anger and heartbreak. It is so easy to wonder, if just ONE thing had gone differently, would these people have their baby alive? I know it's hard. I know it's infuriating, you just want to shake people and say "Don't you get it!?!?!?!" Hang in there. I hope this helps. I don't mean to sound like anybody screwed up in taking care of the family, or like I'm judging, or even that I necessarily agree with all that they did/didn't do. Just trying to shed some light.