confused on 0-10 w.prepidil and events last nite

massbaby · Jan 23, 2010

Was this pt on fetal monitoring at any time ctx pattern what about documenting ctx and FHR what is the hosp policy re induction and monitoring??

NurseNora, BSN, RN · Jan 23, 2010

Of course, not having been there, I can't tell you what happened, only make some guesses.

It's not uncommon for women to go into labor from the ripening agent. Especially multips, which this woman was. If she was being induced for post dates, it's even more likely than if she was being induced early for a medical condition or convenience.

I would have considered her to be in labor by the time she had gone from closed to 4cm dilated and watched her as I would watch a labor patient, even if I had given her Ambien. I ask my patients to use the call bell rather than coming out looking for a nurse because of what happened to your patient. Sometimes there is no one at the desk to ask for help, but a call bell will continue to ring until someone gets it.

A placental abruption (detachment) causes very strong, close contractions and often a very fast labor. It's like the body knows there's a problem and tries to get the baby out a quickly as possible. I think it's more likely to have caused the strong contractions rather than the other way around.

A very tempestuous labor can cause the fetal heart rate to slow because the baby can't get enough oxygen (during the peak of contractions the maternal blood flow is cut off to the placenta; not a problem in normal labor, it's easy to hold your breath for 30 sec every 3 min. But if the contractions are very close, very long, and very strong, that increases the amount of time the fetus has to "hold her breath" and decreases the amount of time that oxygenated blood goes to the placenta). In addition, the part of the placenta that has separated is no longer useful for O2 transport.

By rescusitation, I assume you mean position change, O2 by tight nonrebreather mask, IV fluid bolus, perhaps even some Terbutaline to relax the uterus (although tocolytics are not recommended for use with abruption).

Rapid descent can also slow the baby's heart rate significantly. It's a vagal stimulation from pressure on the baby's head as it comes thru the pelvis.

Was Mom Group B Strep positive? Has she had any antibiotics before delivery? Sometimes patients who are GBS positive with a history of fast labors are induced so that they can get Antibiotics in 4 hours before delivery. Even so, the baby could have picked it up as it delivered. Do you know if the baby had lost blood during the labor because of the abruption?

I know I haven't answered your questions, but I hope I have at least given you some things to think about.

greenykilt · Jan 23, 2010

I thank you so much for your wealth of information and clarity. It astounds me by how much and how great my lack of information is, with that:

mom was negative, no infections.

So when did the placenta start to detach? at the very end or at the moment the mom started to progress in labor from 0cm? if the placenta was detaching wouldn't the strips pick this up well before the mom got to 10cm?

when I pulled up the side affects for prepidil it states: hyperstim and sepsis for infant

trying to peice together where and how you discern between hyperstim caused sepsis, and mom was having a placental detachment that then caused hyperstim etc.

and lastly if you don't mind: what is the "Standard" for watching a mom who is considedered "active labor" how many in person trips or bedside visits is acceptable or not acceptable - legally? or is it just based on the hospitals policy

just wondering if the parents could view the course of the labor as some kind of liability or wrong on the part of the lnd nurse? the husband seemed quite peeved that he didn't see her for so long and then the wife was 8cm etc. add the emotional rollercoaster of the nicu transport etc.

massbaby · Jan 23, 2010

Hi

So many protocols now for cerv. ripening but we try to follow standards. On our unit we can have two pts that are on cervidil ormiso or one cervical ripe pt and do triage but no more. We are only suppose to have one pt on pitocin in active labor 5 cm and more ( this never really get s followed) now pushing!!-- one rn only

pt on magnesium sulfate and pitocin --one rn only

Do you have central monitoring?

greenykilt · Jan 23, 2010

Yes to central monitoring. Does it show the patient contractions too? or just FHR? If you have central monitoring and a patient is in "active labor past 4 cm" do you not need to check on the patient as long as your central monitoring system is showing all is "ok"?

babyktchr, BSN, RN · Jan 23, 2010

There are several things going on here. Prepidil can certainly stimultate labor, especially in multips. I am assuming there was at least 4-6 hours between doses of prepidil, and after the second dose she was in active labor. Active labor standards dictate that the FHR should be evaluated every 15 mins if there is risk and every 30 if not. So, the patient should have been evaluated despite the plan to give her sleep meds and tuck her in. At that point, I would've called the physician to alert him/her to the fact that the patient was in LABOR. At 8cms, the physician should've been called. Multips can certainly deliver very quickly at this point, and it is not unusual in the least. As the above poster said, rapid decent can cause decels.

Even if there were closer observation of the patient, the same outcome could've come about. Multips can go very quickly and even the most prepared can get caught.

LDRNMOMMY, BSN, RN · Jan 23, 2010

Yes to central monitoring. Does it show the patient contractions too? or just FHR? If you have central monitoring and a patient is in "active labor past 4 cm" do you not need to check on the patient as long as your central monitoring system is showing all is "ok"?

The central monitoring will show the contractions and the fetal heart rate. Some central monitors will also show maternal pulse if she has a pulse ox on. My old facility did, the facility where I currently work does not. You still need to check on your patient. We chart on the strip q15 min for high-risk moms and q30 min low risk when in active labor.

greenykilt · Jan 23, 2010

thanks for all your information, its truly very appreciated.

I guess what is hanging me up, is that you hear of how litigious lnd and etc is now a days, something about the look on the husbands face because of how long he tried to find her and how long the break was while the wife was in pain and obviously progressing pretty quickly, made me feel like he was sue spitting mad. (remember the 2 week nicu stay here)

I hate to think about practicing nursing as a CYA type experience, however- could the parents in this situation have a leg to stand on because of the lack of checking on patient? even if same outcome could have occured?

has anyone gotten sued in lnd for things like this? this is my field of choice

greenykilt · Jan 23, 2010

ps she was a high risk patient, pre exsisting hypertension and thus the induction at 36.5 weeks as bp was creeping up.

babyktchr, BSN, RN · Jan 23, 2010

Oh dear.....that adds a new spin. Preterm/late preterm baby, mommy hypertensive....yikes. This fetal heart rate should've evaluated every 15 minutes. As a nurse manager, one of the first questions I would ask is ..where was everyone?? Why did a family member have to come and find someone to assist him? What was going on on the unit, was there an assignment issue, where was the charge nurse, etc? I wouldn't be surprised that there would some reprocussion from this..not necessarily legal, but definintely a complaint that will require follow-up. Only going by what you have described, there seems there may have very well been a ball dropped somewhere.

greenykilt · Jan 23, 2010

not to be completely idiotic, but- if you have central monitoring cant you just monitor every 15 minutes remotely vs in person? am truly asking in such lazy/simple terms just to understand the scope of basic care if that makes sense!