Liability of threatened AB on M/S unit?

queenjean · Jun 13, 2007

Weeel, I've *been* that woman, with numerous hospitalizations even early on in my pregnancies for complications.

I was always placed in an observation part of the L&D ward. I agree that you would want nurses comfortable with a fetal demise as well as nurses comfortable with mag sulfate administering the care. I will note that all the times I was on mag sulfate, I was never on tele.

We don't have a "gyn" floor or "women's health floor" or anything. I can see this pt going to one of those floors, too.

NPinWCH · Jun 13, 2007

My biggest question is why she was admitted to the hospital at all. I know that sounds heartless, but there isn't anything a hospital can do with a 16-18weeker. I work in a rural LDRP dept and she wouldn't have been on our unit, and I know for sure that unless she needed medical attention (ie blood) she wouldn't have even been admitted to the medical floor.

She would have been seen by her doc or the er doc, labs drawn, FHR assessed by doppler then she would have been sent home. I know that sounds absolutely aweful, but really what are we gonna do? If they come in to the ER in the midst of an abortion they stay until they deliver then they usually go home, at most they stay for a few hrs for medical observation.

Our unit is small and we can't keep pts like this since we need all 5 of our beds for laboring/delivering/postpartum moms. If she were 20 weeks she still wouldn't stay with us, though she might end up transferred to the university hospital up the road.

As for liability if she's going to deliver there isn't anything you could do, so there wouldn't be a problem with liability unless you failed to recognize some other issue such as excessive bleeding.

smk1, LPN · Jun 13, 2007

My biggest question is why she was admitted to the hospital at all. I know that sounds heartless, but there isn't anything a hospital can do with a 16-18weeker. I work in a rural LDRP dept and she wouldn't have been on our unit, and I know for sure that unless she needed medical attention (ie blood) she wouldn't have even been admitted to the medical floor.
She would have been seen by her doc or the er doc, labs drawn, FHR assessed by doppler then she would have been sent home. I know that sounds absolutely aweful, but really what are we gonna do? If they come in to the ER in the midst of an abortion they stay until they deliver then they usually go home, at most they stay for a few hrs for medical observation.
Our unit is small and we can't keep pts like this since we need all 5 of our beds for laboring/delivering/postpartum moms. If she were 20 weeks she still wouldn't stay with us, though she might end up transferred to the university hospital up the road.
As for liability if she's going to deliver there isn't anything you could do, so there wouldn't be a problem with liability unless you failed to recognize some other issue such as excessive bleeding.

I was wondering this as well. Was there something else that warranted the admission because I always just thought they would send these patients home with instructions and information on getting rest, fluids to try and avoid the miscarriage, and the possibility of hemorrhage and other things that warrant coming back...

KaroSnowQueen, RN · Jun 13, 2007

First, a 16 to 18 week baby LOOKS like a baby, this is NOT your first trimester "heavy period" type miscarriage. My daughter in law lost her first baby at 17 weeks, and he was a beautiful baby born after two days in the hospital trying to hold onto him. There is EVERY reason to admit her. They monitored the fetal heart tones the entire time. This would be very traumatic to deliver this baby at home.

Secondly, my hospital does not have OB, but our sister hospital does, and they have a special antepartum floor for complications of pregnancy, my daughter was admitted there more than once during her pregnancy. All they do is monitor problems such as threatened miscarriage, premature labor, preeclampsia, etc. No gyn patients, no postpartum, just ladies with troubled pregnancies and they did an excellent job of getting her to 37 weeks.

TazziRN, RN · Jun 13, 2007

My biggest question is why she was admitted to the hospital at all. I know that sounds heartless, but there isn't anything a hospital can do with a 16-18weeker. I work in a rural LDRP dept and she wouldn't have been on our unit, and I know for sure that unless she needed medical attention (ie blood) she wouldn't have even been admitted to the medical floor.

For a fetus at 16-18 weeks, it's not quite so simple to send the mom home. It's not like a first trimester AB....at 16-18 weeks the fetus is quite formed and larger than most women abort. When we send someone home who is vag bleeding and probably aborting, we tell them to come back after the tissue has been passed and bring the tissue with them. I have never seen someone as late as 16 weeks being told that; if they don't abort in the ER they are admitted, either to the floor or OR.

NPinWCH · Jun 13, 2007

I know we are talking about a second trimester abortion. All I'm saying is that a THREATENED abortion won't be admitted to our OB dept or Med/surg.

If we have a fetal demise at 16-18 weeks she would either be admitted/placed on observation in OB for induction/delivery (though sometimes a dose or 2 of cytotec is given at home before she is brought in) or she would have a D&E as an outpt, but she won't be admitted for a threatened abortion.

I guess my point is how long are you going to keep a threatened abortion? She may abort in several hours, several days or never. Bed rest has consistently shown no benefit in preventing preterm deliveries and/or spontaneous abortion (though it does cause all kinds of problems for mom), tocolytics do no good that early in gestation your only recourse is prayer and possibly an emergency cerclage if incompetent cervix is the issue.

Depending on the pt's doc and the attending at our local university hospital a pt may be transferred at these dates, but usually it's the girls who are candidates for a "rescue" cerclage, those with unknown dates, or those at the very edge of 20weeks.

IF this pt had been admitted to our medical unit she more than likely would have been transferred to OB as delivery grew closer, we would have delivered her, stabilized her, provided emotional care and then when she was physically stable she would be discharged.

reesern63, RN · Jun 14, 2007

I'm a new LPN (8 months) on a med/surg floor and would love to hear from experienced nurses about this situation.
Management wanted to place a threatening abortion on our med/surg floor from ER. US showed viable intra-uterine pregnancy between 16-18 weeks; placenta intact. Minimal spotting and some cramping. L/D said they don't take
Supposed to be my admit, but I stated I was not comfortable taking this patient. I'm a new nurse, minimal L/D experience, no fetal or tele monitors on our floor. (Doesn't a mag drip need a tele monitor?)
The charge nurse had numerous conversations with the coordinator and unit manager, but the patient was brought to our unit. By then, the admit fell to the next shift. The patient ended up transferring to L/D on that next shift. I don't know the outcome of the baby, unfortunately.
Was I right to refuse the patient? All I could think of was losing the baby (or the mom!) because we didn't have the knowledge, skills or equipment to identify and prevent such a loss.

There really is little that can be done so early in the pregnancy to maintain viability. Hospital policy would have dictated whether or not she should have been monitored based on being on a mag drip.

smk1, LPN · Jun 14, 2007

First, a 16 to 18 week baby LOOKS like a baby, this is NOT your first trimester "heavy period" type miscarriage. My daughter in law lost her first baby at 17 weeks, and he was a beautiful baby born after two days in the hospital trying to hold onto him. There is EVERY reason to admit her. They monitored the fetal heart tones the entire time. This would be very traumatic to deliver this baby at home.
Secondly, my hospital does not have OB, but our sister hospital does, and they have a special antepartum floor for complications of pregnancy, my daughter was admitted there more than once during her pregnancy. All they do is monitor problems such as threatened miscarriage, premature labor, preeclampsia, etc. No gyn patients, no postpartum, just ladies with troubled pregnancies and they did an excellent job of getting her to 37 weeks.

So what happens while they are admitted? I completely understand that the miscarriage will be traumatic (been there albeit a bit earlier in a pregnancy). Just wondering what the interventions are for a threatened (not currently happening) abortion that isn't at 20 weeks. I just had always heard bed rest, fluids...

Altra, BSN, RN · Jun 14, 2007

I work ER in a hospital with a NICU. Our OB department will evaluate a patient who is 16 weeks or greater. At less than 16 weeks, unless there is fever or other concerning symptoms, at most the patient will go to OB for an ultrasound and then be discharged home with instructions to follow up in the office the next day.

The only

bigsyis · Jun 15, 2007

Yes, you did the right thing. Without experience or monitors, how were you supposed to be able to "take care" of the pt? When I was Charge on Med-Surg, this happened once because of census. The way it was handled was that a L&D nurse came to our floor to care for the pt until they could make room for her on their floor.

Elvish, BSN, DNP, RN, NP · Jun 15, 2007

On our unit (AP/gyn/motherbaby) any pending pregnancy loss under 20 weeks comes to us and we deliver on the floor. They do an u/s to make sure there is indeed a baby (or babies), and wait for her to deliver. Most docs don't order FHTs under 20 weeks. Sometimes they'll do Pit & sometimes not, it depends on the situation. The docs are sometimes not even there for the delivery; most of the time they tell us to call after the placenta is out. Of course, this pt gets 1:1 care during delivery.

I hate doing this on the floor. It is so traumatic for everyone. The first time I was involved in one of these, I couldn't sleep for days afterward. It's a great time to practice the art of nursing but the situation is so dang hard.

PoppaD · Jun 16, 2007

I'm a new LPN (8 months) on a med/surg floor and would love to hear from experienced nurses about this situation.
Management wanted to place a threatening abortion on our med/surg floor from ER. US showed viable intra-uterine pregnancy between 16-18 weeks; placenta intact. Minimal spotting and some cramping. L/D said they don't take
Supposed to be my admit, but I stated I was not comfortable taking this patient. I'm a new nurse, minimal L/D experience, no fetal or tele monitors on our floor. (Doesn't a mag drip need a tele monitor?)
The charge nurse had numerous conversations with the coordinator and unit manager, but the patient was brought to our unit. By then, the admit fell to the next shift. The patient ended up transferring to L/D on that next shift. I don't know the outcome of the baby, unfortunately.
Was I right to refuse the patient? All I could think of was losing the baby (or the mom!) because we didn't have the knowledge, skills or equipment to identify and prevent such a loss.

I'll be brief: this pt should have gone to Antepartum, L/D, or GYN. From the perspective of an ER nurse, she did not necessarily need continuous fetal monitoring, but should have had "spot" FHT's obtained. IMHO it would have been preferable to leave her in the ED until L/D could get its act together. At least the ED could go through the pretense of "having a doctor there" for the pt.