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 ]