Chorio s/s

[MKS8806]

I had a patient recently that spiked a temperature during pushing and the baby was delivered in....not so good shape. The delivering doctor marked on her paperwork that the patient had developed chorio during labor, and I, honestly, didn't see it coming. I've seen patients that are ruptured for 12+ hours that develop a fever and fetal tachycardia, but that was not what my patient presented with. I was wondering if someone could help me identify if I missed something. Here's the scenario:

Patient was sent over from the doctors office due to lady partsl bleeding and non reassuring FHTs. Upon initial exam, she was 4cm dialated with a bulging bag, and scant bleeding (there was just what looked like normal bloody show on my exam glove). She was admitted. The patient was GBS positive and Rh negative. Here initial hemegram showed an elevated WBC count of 25. Within half an hour, I had a 3 minute deceleration that required position change and O2 for resolution. IV access was obtained and bolus started. The patient was now 6cm/80%/-1 station. FHTs following were reassuring. GBS protocol was initiated and the patient received 2 doses of antibiotics prior to delivery. Follwoing the second dose, the physician performed AROM and SVE was 7-8cm/100%/0 station. Temperature was 97.7 oral (pt had not been eating or drinking). The patient also had a small amount of bleeding (more than bloody show) and a small clot was expelled with SVE. We started having variable decelerations following AROM and the patient was complaining of feeling more pressure. SVE revealed she was 9cm/100%/+2 station. An hour after AROM, the patient was complete and feeling pushy. We set her up to push and she pushed for an hour and a half. We were having late decelerations with pushing. A little before 2 hours from the last temperature (which was when she was ruptured), the physician said she was feeling a little warm and wanted a temp taken. She was eating ice throughout the pushing, so we got an axillary temp (which was under a warm blanket) which was 102.8. FHTs were 145-155bpm with lates and variable decelerations with pushing. She delivered the baby 30 minutes later in OP presentation. The last 30 minutes we had minimal to absent variability. When the baby was born, the infant wasn't breathing, and wasn't moving, with a HR above 100 bpm. The baby was flaccid and had a temperature of 103 rectal. After the initial 5 minutes of stimulation, we had poor tone, HR above 100 bpm, and severe grunting, flaring, and retracting with 100% blow by O2. The baby had 2ccs of very thick, yellow, mucous deleed. The baby ended up in SCN with a small pneumo, IV access was obtained and the infant was started on antibiotics prophylactically. I was caring for the infant following delivery, so I'm not sure what transpired with the maternal temp. I did see orders for antiobiotic therapy PO for the mom. The infant's temp dropped to 99.7 Axillary after 20 minutes while remaining under a radiant warmer.

Does anyone have any thoughts or see anything that I might have missed in my care of the patient?? I'm looking to try and make this into a learning experience. I have 1.5 years experience in OB. Is there other presenting symptoms of Chorio prior to delivery that I missed, other than maternal temp and fetal tachycardia?

Thanks for any responses in advance!!

[moonchild20002000]

What about the elevated white count?

[NicuGal, MSN, RN]

The elevated WBC is the first clue. They should be sending the placenta to patho also. And with baby's temp up that high, then mom had a fever also. Baby's overall look at birth is pretty right on with a kid that is septic, and they do also sometimes have a small pneuo due to either stress or bagging. Sometimes it just happens without the usual, nothing is written in stone :)

[shortstuff31117]

I was also going to say the elevated white count. But I didn't see anything else in labor, so even with the white count, I think you'd still just have to wait and see what happens. I've never seen our OBs treat based just on the white count...

[MKS8806]

Thank you all for your responses. They did send the placenta and cultured it as well. We also sent the deleed secretions to the lab for culture - the Ped told me that, if that was infected, that could've caused the pneumo as well.

Thanks again for not....ripping me apart! I've seen some nasty replies on here, but, like I said, I wanted to make this a learning experience! :)

[RNLaborNurse4U]

Elevated WBC and non-reassuring FHR tracing were the red flags. Might be early onset GBS infection (possibly transmitted before labor, with intact membranes). Those kids get sick and fast. What was maternal HR on admission, and throughout labor? How is the baby doing now?

[NurseNora, BSN, RN]

What was her contraction pattern like? Often you see spontaneous tachysystole, as you might see in an abruption. The infection irritates the uterine muscle. Or the body knows it needs to empty the uterus ASAP!

The WBC is usually elevated just by being in labor, so that's not as big a red flag as you may think. Don't beat yourself up about it.

You don't mention an epidural. If a patient feels warm to the touch and her oral temp is normal, I'll take an axillary temp. A patient in active labor does a lot of mouth breathing and I find that an axillary temp is often more accurate than an oral one.

You knew you were going to have a sick baby requiring resuscitation by the strip--lates and absent variability for a good period of time. You were, I assume, prepared for this. I can't think of anything that you would have done differently if you had recognized chorio. She was already on antibiotics. The doc might have added another one to increase coverage--or not.

The only recommendation I have for you is to believe your hands when a patient feels hot and believe an axillary temp.

[MKS8806]

Yes! When I saw the WBC count, my initial reaction was that women in labor generally do have slightly elevated WBC counts. But later (after delivery), I wondered if that should've been a flag.

Mom did receive an epidural and her vitals were WNL on admission and throughout the labor ... until the end of course.

The baby and mother are doing fine and have been discharged. Baby's blood cultures came back negative.

Thank you all for your cordial repsonses. This has really been a learning experience. I truely love my job. In fact, every delivery I am priveliged to be apart of, I feel so lucky and honored to be apart of that experience with the family. I also love that I am constantly learning in this field - keeps me on my toes!

[RNLaborNurse4U]

An admit WBC of 25 is NOT normal for labor. Even if she is in an advanced stage of labor upon presentation. WBC in labor does gradually rise (to the teens), but doesn't have the abrupt rise as it does in the early postpartum period -- where it can go upwards around 25 (and be totally normal!)