venting: fetal demise

[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.

[lupin]

While all nurses see problems with patients' health caused by their own poor choices, none to me is more heartbreaking than when it affects infants/children. It is so easy to get angry and furious at them and most of the time they are in such denial we end up on the legal side of it, but we have to just keep plugging away at the education part and their choices still remain their choices.

Take good care of yourself and stay focused on the fact that YOU did what you could do for her and the baby. Perhaps next time she will pay more attention to what the diabetic education tells her.

[MaryAnn_RN]

Yesterday I was priveliged to care for a patient and her family. She had undergone an emergency C Section and the baby was very sick but alive. He died at one day old just after he had been baptised. His mother was too sick to be with him but dad was there. We were trying to avoid intubation, she was on CPAP but I took it off briefly while her husband told her that baby had passed. If I say it tore my heart hearing her cry it would be an understatement. Afterwards they brought the baby to ICU. The mothers face was so serene and utterly beautiful while she held and kissed him.

[cardiacRN2006, ADN, RN]

Yesterday I was priveliged to care for a patient and her family. She had undergone an emergency C Section and the baby was very sick but alive. He died at one day old just after he had been baptised. His mother was too sick to be with him but dad was there. We were trying to avoid intubation, she was on CPAP but I took it off briefly while her husband told her that baby had passed. If I say it tore my heart hearing her cry it would be an understatement. Afterwards they brought the baby to ICU. The mothers face was so serene and utterly beautiful while she held and kissed him.

Gosh, that must have been really hard to deal with.

[GrammaKay]

"I think God makes our assignments those days."

A very good friend of mine reminds me of this when I ask "why me". Usually further down the road I can look back and say yes, I was meant to be there. Sometimes it is for my patient and sometimes I believe it is because there is something I need to learn. As painful as it is I think I am stronger for it.

Thank you for your response to this note, your words bring comfort to those of us who deal with such difficult situations and help us to move forward, stronger for it.

Gramma

[YellowFinchFan]

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.

:nurse:Thank you for sharing I really learned alot from your post - We have many hispanic patients at my hospital and because of what you shared from your experience I can now somewhat understand the non compliance andobstaclesthat these patients face when they are at home and "non compliant"....

I think we need to think "out of the box" when trying to relay such important information for mother and baby's wellbeing.....

This is a sad story for all involved

[YellowFinchFan]

Yesterday I was priveliged to care for a patient and her family. She had undergone an emergency C Section and the baby was very sick but alive. He died at one day old just after he had been baptised. His mother was too sick to be with him but dad was there. We were trying to avoid intubation, she was on CPAP but I took it off briefly while her husband told her that baby had passed. If I say it tore my heart hearing her cry it would be an understatement. Afterwards they brought the baby to ICU. The mothers face was so serene and utterly beautiful while she held and kissed him.

It never gets easy and it never should. These are moments that are forever in our hearts :redbeathe

[cherokeesummer]

I'm sorry, how very sad. I'm a type I diabetic and it took many years for me to conceive so I assure you this when I did, (after 9 years) I was the best diabetic I've ever been in my life, wish I could say the same now, horrible control right now, but during my pregnancy I was strictly controlled and thankfully my son is now three years old and had no problems at birth other than some hypoglycemia and spent the night in the NICU, also he was very big (11 lbs). My A1C was 5.9 during pregnancy and really I felt very good.

I have cared for a couple of fetal demise patients (I'm a pp nurse) a nd its so hard, I don't ever know quite what to say, especially those that are full term.

Sorry