20 wk fetus, prom

Specialties Ob/Gyn

Published

Hi, I have a "hypothetical" question. A Grand Multip presents to ob from er c/o big gush of water 4-5 hours ago, no bleeding. er docs get a positive Nitrazine, do a U.S. : live fetus, everything mormal but no amniotic fluid noted, consistent with rom. est g.a. of 20 wks 1 day, 489 gm.OBGYN reluctantly comes in, does sve, no speculum. ( 1/thick/high , no fluid noted ) and tells pt she needs to get pitocined and that baby is not viable. pt is devastated, of course asks that we do everything for her baby. call 5 hospitals with nicu, no beds. get neonatology team on standby. OBGYN maintains non-viability of baby, neonatologist will not take that risk. hospital has only well-baby nsy. this is say tuesday evening. By thursday evening, after 2 days of pit, with nights off. pt still 1/thick/high, only mildly cramping from 20m.u. pit, remains afebrile, not treated with antibiotics (prom more than 52 hours). no fluid noted during these 2 days, unable to reach to feel membrane (or not). Is it me or is there possibly a problem with this picture. no repeat U.S., 2 negative ferns ( which is always negative anyways, from my hospital !).

Now, should OBGYN not do at least speculum exam, repeat U.S., keep trying to transfer pt, not induce...of course the debate is over the viability of that fetus. Say it isn't viable....should we not make darn sure that it is a definite rom, not pit and observe. What if she's not ruptured and the 1st U.S. was off. Perharps this pt (and her fetus) have a better change if they just go AMA

What about Dex and Amnio-infusion, if prom ?

This " hypothetical " problem is really gnawing at me. I would appreciate any suggestion, feedback.... I guess my big issue is that say she's not rom and we pit that baby out at 20 wks ? ...major blooper right ? :crying2: :angryfire , Thanks, Minou

Wow, maybe the hospitals ethics committee should be contacted regarding this hypothetical case. Has anyone talked to this patient and the family of this lady and told her that more could be done to save her baby? As a patient advocate, I would think that someone should (hypothetically of course.) They could request transfer or leave AMA if needed and drive to another hospital. She does not sound like she is in danger of delivering soon with that long on pit and no change. ...Or, maybe a complaint should be filed on the physican. I know there is not really enough information here, and I now I am rather naive about this type of situation (we would have transferred this type of patient immediately at our place) but it smacks a little close to murder to me. :crying2:

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20 weeks? Depending on how stable mom is, we would do all we could to get her transported to a higher-level facility (we are level 2 only) and let them handle it. It's a case-by-case thing. A person presenting grossly ruptured, in advanced state of dilation and infected is quite a different case than one who presents "leaking" and closed/thick and stable at the time. You have to take into consideration the whole clinical picture and treat accordingly.

Our local level 3 will not take them under about 24 weeks. A couple of times, we (as a level 1) have kept a mom for 2-3 weeks until the level 3 would take her.

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Ok, in this hypothetical situation what kind of relationship does your doc and nurse manager have? Have these concerns been stated to the doc and nurse manager? A big part of my job is patient advocate. I've been known to ask the doc why not this or why this or what about this. There is always medical review , ethics committee. As a nurse I don't have to just sit back and watch what I feel is inadequate treatment of my patients. My name is the one on that chart day to day, I am the one administering the pitocin and I am responsible for the care I give. Ask questions, make the doctors accountable, use your chain of command. Document document document ..... MD in....MD refuses to repeat US feels spec exam not needed.....MD states no antibiotics needed......etc... make sure your doc is aware that his responses will be documented.

At my hospital as long as we have good fetal heart tones we do everything possible. Antibiotics, bedrest, mag, trendelenburg, dex, stablize this mom and transfer her. Our doc is wonderful about calling the regional facility for a consult if the patient isn't stablized enough for transfer. He's also real good at listening to and answering the nurses questions regarding patient care. It makes him think sometimes and we learn alot from each other.

Wonders how this hypothetical situation will end??

PS as for the ER...if the patient is 20 weeks they don't even look at her, she comes straight from registration to me. They shouldn't tell my moms anything about her care other than that we'll do all we can and take good care of her.

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Specializes in L&D.
Ok, in this hypothetical situation what kind of relationship does your doc and nurse manager have? Have these concerns been stated to the doc and nurse manager? A big part of my job is patient advocate. I've been known to ask the doc why not this or why this or what about this. There is always medical review , ethics committee. As a nurse I don't have to just sit back and watch what I feel is inadequate treatment of my patients. My name is the one on that chart day to day, I am the one administering the pitocin and I am responsible for the care I give. Ask questions, make the doctors accountable, use your chain of command. Document document document ..... MD in....MD refuses to repeat US feels spec exam not needed.....MD states no antibiotics needed......etc... make sure your doc is aware that his responses will be documented.

At my hospital as long as we have good fetal heart tones we do everything possible. Antibiotics, bedrest, mag, trendelenburg, dex, stablize this mom and transfer her. Our doc is wonderful about calling the regional facility for a consult if the patient isn't stablized enough for transfer. He's also real good at listening to and answering the nurses questions regarding patient care. It makes him think sometimes and we learn alot from each other.

Wonders how this hypothetical situation will end??

PS as for the ER...if the patient is 20 weeks they don't even look at her, she comes straight from registration to me. They shouldn't tell my moms anything about her care other than that we'll do all we can and take good care of her.

Wow, where to start...

A pregnancy loss at 20 weeks is termed a mid trimester abortion. Perhaps the patient overheard the ER nurse use the term in report to another nurse. It's not a term I'd use directly to the patient as most nonprofessionals think the word abortion only means to electively end a pregnancy.

Pitocin doesn't work very well at 20 weeks. There aren't very many receptor sites yet. Cytotec or prostiglandin suppositories work much better that early in the pregnancy. I've also used laminaria. Looks like a small brown twig, it's made of compressed sea weed. Inserted into the cervix, it absorbs moisture from the lady partsl secretions and swells, manually dilating the cervix the first centimeter or two. I can't believe your doc was trying to use Pit.

I've seen babies born with undeveloped lungs after rupturing at 20 weeks or less. If the membranes seal off and the baby stays surrounded by fluid, it can practice breathing in utero. If the fluid is all gone and there is no fluid surrounding the baby, the lungs can't develop properly.

I can't believe a neonatologist wouldn't come to talk with the parents and discuss the chances for survival and what could be done. I can't believe a perinatologist wouldn't come in and talk with the patients about the possible options for treatment. I can't believe no one told the patient to walk out of your hospital and present herself to a level 3 center.

I've seen everything from doing nothing and letting labor start when it was ready to start to inducing immediatly, to most everything in between. When your baby is alive, but not viable, how proactive do you want to be? Do we monitor the heartbeat and do a C/S for distress? It is still major surgery and do we want to risk maternal morbidity for a nonviable fetus? If the answer is yes, then do so. If you're not going to do anything for distress, no reason to monitor. I've had patients decide not to go for a C/S, but they wanted to be sure the neonatal team was present at delivery just in case the baby was further along than anyone thought. I've seen the neonatologist act on some and gently take the infant to the parents and show them just how immature the baby is and that even though the heart is still beating, the baby is just too immature to live. I've stayed with parents while they held their tiny, tiny baby until the heart beat stopped.

There are so many options, it's sad that your poor hypothetical patient didn't hear about many of them. How did this finally turn out?

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this whole thread makes me so sad :o i'm only a nursing student right now, but i've been shadowing at the local women's hospital. last time i was there, we had a 22 weeker come in with slight cramping, so the docs did all the standard tests and cultures, no sve but speculum exam showed cervix to be about a fingertip. baby sounded good but the nitrazine came back positive and ferning was "positive" (it was weird, it didn't look like normal ferning, way more wispy), but there was also a possibility that the mom had intercourse within 24 hours (she couldn't remember the exact time), so could that have affected the test? u.s. showed normal fluid. anywho... the doctors decide that her options are to induce, to terminate (i can't remember the exact term, but it's like an abortion, d&c maybe?), or to try to continue the pregnancy. they made a huge effort to "paint the grim picture" to this young (only 19 y/o) patient. it just felt so wrong to me. like they were pressuring her into ending it. i so wanted to say something, maybe suggest a repeat of some of the tests, but as a student it definitely didn't seem like my place to say something like that. i'm just so sad for this poor patient :crying2: am i wrong here? or should the docs have been making more of an effort to save this baby? ok... done venting... thanks

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In the hypothetical situation, we would not transfer a 20 weeker regardless of SROM, spontaneous labor, etc. We would however, try to maintain the pregnancy with bedrest, IV fluids, mag if necessary.

I work in a Catholic facility. We will not induce any pretermers with SROM if FHT are present, unless Mom is becoming febrile.

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