Ethical Dilemma

burn out · Jan 25, 2007

Please I am not an OB nurse so may I don't know what I am talking about, but I know that they will let a woman carry a demised fetus until labor sets in so what was the rush with terminating this pregnancy..how did the mother feel..was it sure to have birth defects.

judyblueeyes · Jan 26, 2007

Sorry if my tone was harsh. Sometimes I sense a bias in the phrasing that makes me think that the scenarios are there to support the presenter's

point-of-view.

I could be wrong about this.

Please I am not an OB nurse so may I don't know what I am talking about, but I know that they will let a woman carry a demised fetus until labor sets in so what was the rush with terminating this pregnancy..how did the mother feel..was it sure to have birth defects.

There are several reasons why someone may want to terminate the pregnancy in the scenario.

One reason is that the lack of fluid does not necessarily mean the pregnancy won't progress- to term even- it just shows that something is very wrong. We don't know what.

Another is that if a family does decide to terminate a pregnancy, it may be less difficult to terminate early- emotionally and physically.

Another is that this pregnancy may progress to viability (generally considered 24 weeks) or more, only to be born 'without lungs' and a generally dire prognosis.

Another is that it is very difficult to stop treatment, even if the treatment is futile, once treatment is begun. In the worst case scenario for the hypothetical situation, this baby may reach viability or more only to suffer a very long and painful course.

Your question about how the mother feels is the primary question in my mind. I think families should make the decision that suits them best.

This family might opt for genetic testing (no amnio though- no fluid!), see a high risk perinatal specialist for a second opinion, and decide to try to go for term no-matter-what, hoping for the best.

I would support that also.

Suggested reading:

Books: "Playing God in the Nursery", "The Long Dying of Baby Andrew" and the Sidney Miller wrongful life situation (online http://www.csmonitor.com/2003/0327/p01s01-usju.html).

htrn · Jan 26, 2007

I work in a Catholic Hospital, so this situation would go through our eithics committee. We had a situation a few years ago with a 20 weeker that seemed to be progressing through Pre-Eclampsia to HELLP syndrome in a matter of hours. Of course this happened in the middle of the night on the weekend, but they called an ethical consult because they decided they had to terminate the pregnancy in order to save the mom's life. Turned out she had a partial molar pregnancy.

We have had other situations where the infant had a known anomalies incompatable with life and the patients were offered early induction (before viability), but they decided to wait until 36 weeks or natural labor and let the infant die on their own - comfort measures only. Like I said thought, Catholic hospital with a large Catholic patient population.

Back to the orignal question though - that's why we have a team that we can call day or night for ethical consults. If there were an ethics consult called and it was decided to procede with the induction, then anyone involved in the patient's care would be given the option not to participate for moral, ethical, or religeous reasons. They really do stick to this last sentence - absolutely no repercussions if you do not want to participate, they just get on the phone until they find someone who can come in to care for the patient.

33-weeker · Jan 27, 2007

With all the fancy prenatal testing these days, can't they diagnose this?

If it is Potter's (renal agenesis), couldn't they see that on US?

I've known of pregnancies induced pre-viable for which it turned out that the fetus was not as defective as suspected and could have lived if allowed to go to term. I personally lean toward letting nature take its course. But if the parents have gotten a second (third, ...) opinion and feel this is what they want, then so be it.

May_baby · Jan 27, 2007

Going back a few posts, I think I picked up on someone asking about the timeline for induction after fetal demise.

I think I understand that induction after FDIU is important in some cases to prevent DIC and the like? I'm not a student yet, but it might be helpful to myself and others to understand why there is a protocol for induction/D&Cs after fetal demise.

(I understand that the original post was an ethics question about a currently living fetus, sorry to sidetrack!)

judyblueeyes · Jan 29, 2007

With all the fancy prenatal testing these days, can't they diagnose this?
If it is Potter's (renal agenesis), couldn't they see that on US?

They did diagnose it (oligo, anyway). What else do you want them to diagnose? The next step is to decide what to do.

I've known of pregnancies induced pre-viable for which it turned out that the fetus was not as defective as suspected and could have lived if allowed to go to term.

How could you possibly "know" this?!

I personally lean toward letting nature take its course. But if the parents have gotten a second (third, ...) opinion and feel this is what they want, then so be it.

Me, too.

judyblueeyes · Jan 29, 2007

Going back a few posts, I think I picked up on someone asking about the timeline for induction after fetal demise.
I think I understand that induction after FDIU is important in some cases to prevent DIC and the like? I'm not a student yet, but it might be helpful to myself and others to understand why there is a protocol for induction/D&Cs after fetal demise.
Not everyone with a FD gets DIC. I'm not sure why. We recently has a pt with twins with a FD at 24 weeks who went to 36 weeks with the remaining fetus. I also saw a picture of a fetolith before.

Elvish, BSN, DNP, RN, NP · Jan 29, 2007

I think what 33-weeker was asking was if the root cause of the oligo could've been diagnosed by u/s.

There is usually something that causes oligo, but sometimes that something is as simple as dehydration.

I'm not saying I know what is wrong or right here. It is an extremely tough call and I hope I never have to make it.

crissrn27, RN · Mar 16, 2007

hey, what happened with this patient/family, stillbelieve? Or did I miss something and this was a hypothetical case?

33-weeker · Mar 19, 2007

I knew of a pre-viable baby aborted via labor induction due to 'anomalies incompatible with life'. The baby on autopsy (how I 'know') showed a couple of minor anomalies that could have been fixed surgically. This baby could have lived a normal life with treatment. Too late now, though.

lovemyjob · Mar 20, 2007

We had a situation where a severe oligo (polycystic kidneys)from early pregnancy was given amnio infusions throughout pregnancy to assist lung development. At about 33 weeks was bron with right decent lungs and nonfunctioning kidneys.... was on peritoneal dyalysis for months then dies suddenly of GI perf.

Many of us questioned the OB's decision to actively keep this pregnancy and infant viable. Knowing the chances of a kidney transplant and the likelyhood of that being successful, given that she survived long enough to grow to an appropiate weight. It was difficult to watch, especially after the mother had been given so much hope from the OB.

33 weeker, it really does kill me to think that parents make decisions re: life and death over a triple screen or over an ultrasound. How many times have you gotten one thing in report about suspected whatever on ultrasound and found a different scenario on admission?

OP, does your hospital have a protocol for pregnancy termination? You miht want to take your concerns to either your NM or he ethics committee. This way you will know your hospitals rules for the next time.