How would your hospital have handled this nightmare delivery?

  1. A friend of mine had a baby about three weeks ago. She was a primip with an uncomplicated pregnancy until the 7th month when she began having high BP and gestational diabetes. She was seeing her primary FP for her care and went to the office at 8 months c/o headache and severe fatigue. I'm sure you've all guessed by now she had toxemia. Her FP induced her that very day ( of the office visit) and here is where it gets messy. She labored for several hours and was then given an epidural because she was not progressing as well as expected, and the FP thought she would relax and dialate. Her BP had risen to 160/100 when she was given the spinal (Isn't that red flag #1?). After an hour on the spinal, her BP was holding steady in the 160's and began climbing to 180 a little later when she was dialated to 7cm. Her FP freaked out b/c of the BP's and told her to start PUSHING! (Isn't this red flag #2?) How common is it for a woman to push at 7cm? Isn't that near impossible? My friend reported hearing the doctor and two nurses having a heated discussion right in front of her about the pushing. The nurse was saying, "Don't you want to do a C-section?" and the FP was saying, "Push Nicole, push!" The nurse was resistent to this and kept telling Nicole NOT to push! Anyway, by the powers that be, she delivered a 8# boy and hemorraged for 2 hours where upon the nurse called the blood bank to get a few units and the FP stopped her. I'm not sure how much blood Nicole had lost, but it was enough that Nicole had passed out at this point and woke up the next day with a very angry hubby, a new baby and about 100 stitches holding her insides together. She was released from the unit 3 days postpartum and had a stroke at home the next day.

    I am not an OB nurse. I am somewhat knowledgable with routine OB stuff, though and here are my many questions.

    #1 When her pg was decided to be high risk at 7 months b/c of the BP's and diabetes...why wasn't an OB consult done fro continuation of high-risk care? Shouldn't a consult have been made?

    #2 Why on earth would a woman be told to push at 7cm when her labor had been progressing so slowly inteh first place? With a BP in the 180/100, wouldn't a c-section have been warrented?

    #3 Why would the FP stop a blood infusion? Nicole was told by the nurse that she had hemorraged for 2 hours and was then in surgery for another 2 hours to stitch her vagina, cervix and perineum due to the severity of the birth.

    4# Would a blood infusion saved her from having a stroke? She is luckily recovering from her stroke, but is having left sided tingling and intermittent numbness in her left face and hand.

    Should she consider bringing this to the medical board?

    Thanks for listening and for your answers.

    Lisa
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  2. 8 Comments

  3. by   Nursz-R-Awsm
    I have just graduated from nursing school, but I know enough that this scares me! #1/consult? YES! #2/Push at 7??? No way! #3/I don't know why he would stop it. #4/I would think so, but not sure. I hope they do something about this. She is so fortunate that she has not lost more from the stroke...should she talk to a lawyer? Hey, maybe feistynurse could give some advice???
  4. by   OBNURSEHEATHER
    I'm not an L&D nurse, but this doesn't sound good to me. On the post partum unit that I work, a lot of high risk patients, even those who have seasoned OB docs, are transferred to the care of the Maternal/Fetal Medicine Specialists. Even the women who stay with their FP's, the 24 hour OB attending doc attends the birth in case something "comes up".

    Hopefully some of our good L&D nurses will shed a little more light on this one for you!

    Heather

    [ May 25, 2001: Message edited by: OBNURSEHEATHER ]

    [ May 25, 2001: Message edited by: OBNURSEHEATHER ]
  5. by   sis
    I believe the FP should consider a new line of work. Maybe flipping burgers at McDonalds.
  6. by   rdhdnrs
    Oh my, what a nightmare!
    First off, yes, I believe that if the FP did not have experience handling severe preeclampsia, which it sounds like this lady developed, he should have referred her at the point she started developing pressures and protienuria.
    Secondly, I don't understand having someone push at 7cm ever; you're asking for a cervical laceration. BP 180/100 by itself is not necessarily an indication for c/sec, but if the pressures are rising and there is a failure to progress, I would go to the OR. If this girl was being induced for preeclampsia at 8 months (how many weeks?), she had an unfavorable cervix. With worsening disease, arrested or nonprogressing labor remote from delivery is an indication for c/sec.
    As to the blood issue, it sounds as if maybe the patient was developing HELLP syndrome if she was bleeding that bad. If so, she probably needed platelets as well as PRCs.
    The original posting didn't make clear if the delivery ended up being a section or not, so the blood loss issue is kind of murky for me.
    If this horrible situation had happened to me or mine, knowing what I know as an OB nurse, if indeed it all happened as stated, I would probably at least talk to an experienced attorney, who handles this sort of thing often. I am not in favor of litigation as a rule, but if indeed things proceeded as you say they did, this doc and this hospital have major problems. It would bear further investigation.
    Good luck, and I hope Nichole and her little one are improving.
    Lisa
  7. by   Q.
    My lord, what a delivery! I'll see if I can shed some light on this, but this is why I don't like Family Practice getting too involved in deliveries.

    Usually FPs can do high risk deliveries - a consult is not warranted but usually prudent. At the time that her pressures didn't go down, an OB should have been called to come and assess the situation and give a consult.

    I can see giving an epidural/spinal in an effort to relax the mother in order to progress. The pressures rising after placement, however, is odd to say the least. Epidural/spinal narcotics typically LOWER pressures. At this point, I would have expected Magnesium Sulfate to have been initiated, especially if she was not near delivery. It is at this point that an OB should have been consulted.

    I am suspicious of the high pressures, however. Was she truly preeclamptic? In order for preeclampsia to exist in the clinical sense, the BPs have to be accompanied by proteinurea, elevated AST and ALT and platelets - AS WELL AS - edema, headahce, blurred vision, etc. However, the diabetes and high pressures were signs enough to warrant the induction. But I am starting to wonder if the spinal didn't play more of a role in her hypertension.

    FPs can't do sections. It is this reason that this FP felt he had no choice other than to make her push. Pushing through an incomplete cervix is asking for a cervical laceration - hence, her blood loss. If the FP felt the baby was low enough, at +1 or more, and perhaps the cervix was 7cm but very, very, very effaced, there is a slight possibility that the cervix could be manually dilated to complete. However, for this to be done, that FPs hand had better been up there in her vagina throughout her pushing.

    It is all hard to say, without having been there. The primary concern was to get the baby out - assuming the baby was showing signs of distress, or assuming Nicole was going to seize with those pressures. If the baby was distressing, then yes, getting him/her out was first and foremost - if a vaginal delivery was the quickest way. Perhaps an OB wasn't close enough to start the section, perhaps the baby was, like I said, at a +1 or lower. Perhaps the risk of a cervical laceration was far better than the risk of her seizing and the baby suffering hypoxia. I don't know. What I would have expected, that if the pressures were that high, and she was not complete and not near delivery, then magnesium sulfate should have been started.

    As far as the blood loss goes - Nicole could have passed out from exhaustion - not necessarily blood loss. Her H&H, or her EBL (estimated blood loss) at the time of delivery, is what would usually be the deciding factor for infusing a couple units in. Not passing out alone. Blood loss can also be controlled by medications on the floor - such as pitocin, methergine, or hemabate.

    Again, the stroke/high BP/association with the spinal all has me concerned. If she stroked out, my guess is her pressures were still significantly elevated - and hard to control. This could also be why the FP didn't want the extra units of blood to go in. Adding a couple units of blood to an already severly hypertensive mom might not be the greatest idea. Sounds to me like she could afford to lose at least 800cc and still be asymptomatic.

    I am not certain if she has a lawsuit or not. From the sounds of it, Mag should have been started in the least, assuming she is truly preeclamptic, OR, her pressures were high enough that one would be scared of seizing. Secondly, the RN arguing in front of the patient with the MD was also very unprofessional - telling her NOT to push and the MD telling her TO push - not good. No wonder her pressures were elevated. I have been in situations like this and I simply would have the MD do what he wanted - if he wanted her to push at 7cm, then by god he better be in there telling her to, because I am not. Also, I have called our OB section chief when there has been concerns about a FP - and if it looks like a consult should be done, then you as the RN should do it.

    My opinion? What are her damages? Did she suffer permament damage from the stroke? If so, then she may have a lawsuit. If not, then it looks to me that she suffered a stressful delivery - but delivered a healthy baby.

    [ May 26, 2001: Message edited by: Susy K ]
  8. by   CMAtoRNPLZ
    Thanks for all the advice on this. I'm not exactly sure of the entire situation, having only heard it first hand. But a lot of things made me nervous about it. I work at the clinic connected with this hopsital and know that the OB on-call is always in the hospital after 6pm, so I'm not sure why he wasn't consulted right away. Nicole's delivery was vaginal, and she had a severe laceration ot her cervix, amoung other places. I'm not sure if she will pursue anything or not. Thanks again!

    Lisa
  9. by   fiestynurse
    There are so many unanswered questions here. Why was this woman not put on Mag Sulfate? Why was an Ob doctor not consulted when this turned into a high risk pregnancy and delivery? Sounds like this woman basically had a vaginal C-section, as we like to call it! She should have been on Mag post delivery, also. Of course she stroked after all this and it could have been prevented! I would see an attorney if I were her.

    I would also like to add, that in the present managed care (managed cost) system we are seeing situations like this more and more. Primary Care Doctors are being pushed to provide complex care without specialists.
    According to a recent study 40% of primary care doctors in California say that the complexity/severity of patients that they see is too high. Another dangerous situation created in order to cut costs!!

    [ May 26, 2001: Message edited by: feistynurse ]
  10. by   kennedyj
    Sounds like she would have made a good Mag /Pitocin induction. I would be sweating if I were that FP in hopes of not getting sued from this. Some FP's can c section with special training but do to the preeclampsia at the very minimum the delivery should have been co-managed with an Ob/gyn. She could have been put on Mag and pit and easily delivered even if the Bp's stay high.
    In Europe I see know of many providers that would have manually dilated her to 10cm although not a practice in the Us for fear of the rare possibility of rupturing the cervix. Pushing is a great way to rupture is just about every time.
    J

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