Corey Narry

Case Study: An OB Catastrophe

Case Study Objectives Present a simulated case as it evolves over time. Encourage open discussion from nurses that represent a variety of specialties. Promote learning based on the: details of the case evaluation of the data known interventions in order to provide holistic care Recognize maternal morbidity and mortality as a serious public health issue facing the world. Introduction The initial presentation that will proceed is meant to set the tone for the next set of events that will occur. I would like to preface by saying that this particular part of the case is where I have no actual nursing experience so I encourage colleagues who work in this specialty area to chime in with their responses. Let's keep this lively, but also make sure we are respectful of each other.  Remember that we work in different hospitals and protocols may be different.  Also, be aware that while the following scenario seems "garden variety", it will get more "exciting" as we move along. Case Specifics History / Presentation EJ is a 32-year old, Gravida 4 Para 2, at 34 weeks and 2 days gestational age. She has no chronic medical problems but admits to current tobacco smoking since age 17.  She says that she has been trying to quit and has cut back her smoking to 2-3 cigarettes a day.  She lives with her husband and two children ages 3 and 5 in a 2-bedroom apartment.  She receives prenatal care at an urban Federally Qualified Healthcare Center (FQHC).  She previously worked as a server at a restaurant but has become unemployed for a couple of months due to restaurant closures from the coronavirus pandemic.  She has good family support from her parents and her husband, RJ, who is a delivery truck driver.  She is insured through her husband's coverage.  Today, she called her Women's Health Nurse Practitioner (WHNP) when she experienced a gush of watery fluid from her lady parts while playing with her children.  She was told to come to OB Triage at the nearby Tertiary Medical Center Antepartum Unit.  Upon presentation, she was seen by the OB Triage nurse who found her anxious but well-appearing.  Vital Signs Temperature: 36.7 degrees C Heart Rate: 84 Respiratory Rate: 16 Blood Pressure: 112/74 O2 Saturation: 96% RA Fetal Heart Rate (FHR): 140 Physical / Pelvic Examination An OB-Gyn resident saw EJ and performed a physical examination that revealed clear, pale yellow, odorless fluid leaking out of her endocervical canal with pooling in the lady partsl vault. Diagnostic Studies The OB-Gyn resident performed ultrasonography which revealed: oligohydramnios a fetus that is small for its age, without birth defects, in no distress a placenta that does not cover the cervix Recommendation The OB-Gyn team recommended admission to the Antepartum Unit. Diagnosis At this point, EJ's diagnosis seems obvious but you are welcome to state it in your response to the thread. 1 - As EJ's nurse, state some assessment findings that would make you concerned.  2 - As the nurse in that unit, what laboratory tests and monitoring procedures would you anticipate in this case, and why?
Hospital Day 3 EJ has received a course of corticosteroids.  Her fetus was found to be in the ideal cephalic presentation.  The OB team decided on labor induction with oxytocin as there were no contraindications identified.  EJ requested an epidural and a CRNA placed the catheter successfully.  Continuous epidural infusion of ropivacaine and fentanyl was started. Focused Nursing Assessment: Neuro: alert and oriented, anxious CV: S1S2 normal, NSR with HR 87, BP 122/80 Pulm: lung sounds CTAB, O2 sat 99% on RA GI/GU: gravid abdomen, odorless and clear lady partsl discharge ID: Temp 36.5 Labs: WBC 11 k/UL Hgb 12 g/DL Hct 33% Plt 150  k/UL INR 1.1 PTT 30 sec Fibrinogen 300 mg/DL Type and Screen O positive GBS not detected HIV negative COVID 19 PCR not detected Delivery Course: EJ had an uncomplicated labor course thus far and delivered a low birth weight baby girl.  Her newborn was transported to the Neonatal ICU. Within 30 minutes of manual placental removal, EJ stated "I am not feeling well" and immediately became unresponsive.  Within seconds, she was pulseless and blue.  A Code Blue was called.  Teams from Anesthesiology and Adult Critical Care Medicine arrived to assist the OB team.  The anesthesiologist was able to secure a #7.5 endotracheal tube and ventilate while the rest of the Code Blue Team did CPR.  Medication administration following ACLS protocol for asystole was carried out.  An arterial line was placed in the left femoral artery emergently. During the event, she started gushing blood out of her lady parts.  A percutaneous sheath introducer (PSI) was emergently placed by the ICU team on the right femoral vein and Massive Transfusion Protocol (MTP) was activated.  Using a Rapid Infuser, a total of 8 Units of PRBC, 8 Units of FFP, and 4 Units of platelets were rapidly transfused. The OB team placed a Bakri balloon for temporary hemostasis. Return of Spontaneous Circulation (ROSC) was achieved after 30 minutes. EJ was transferred to the ICU. Post-Arrest assessment: Neuro: unresponsive to stimuli, pupils are equal 3 mm, reactive to light CV: S1S2, Tele: Sinus Tach 110's with some PVC's, Arterial Line BP of 93/50 with MAP of 67, CVP 18. Pulm: Lung sounds coorifice bilaterally. Os sat 95% (see vent settings) GI: abdomen soft, ND, hypoactive bowel sounds GU: Bakri balloon and Foley catheter in place Extremities:  cool to touch, slow capillary refill ID: temp 36.2 C Medications: Propofol at 30 mcg/kg/min Epinephrine at 0.03 mcg/kg/min Norepinephrine at 13 mcg/min Vent settings and lung mechanics: Ventilated on Assist Control/Volume Control, set RR 28, VT 350 (calculated as 6 cc/kg of her predicted body weight), FiO2 100%, PEEP 15, peak airway pressure 32, plateau pressure 26. Imaging: CXR: CT brain: No large vessel ischemia, multiple small vessel supra and infratentorial embolic infacts. CT abd/pelvis: hepatic infarcts. Transthoracic Echocardiogram: LV dysfunction with EF 35%, regional hypokinesis in the mid and apical segments. RV function and volume were normal. No valvular disease. IVC was full and does not collapse. Laboratory Data: WBC 14 k/UL Hgb 8.4 g/DL Hct 24% Plt 34 U/L INR 2.4 PTT 63 sec Fibrinogen 73 mg/DL AST 960 U/L ALT 752 U/L total bili 3 mg/DL alk phos 320 U/L Na 133 K 3.7 Cl 100 CO2 23 BUN 30 crea 0.8 ABG: pH 7.28 paCO2 50 PaO2 134 HCO3 22 Base excess -3  95% lactate 3 BNP 950 Questions: What do you think happened to EJ? Putting all the data together, make some inferences on what the labs and diagnostics mean. What next steps would you anticipate? ICU nurses I expect a system-based response, ie, plan per Neuro...CV...Pulm, etc.
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