OB Emergencies- kind of long

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Okay this is kind of long but I would like your opinions on this. Let me give you a little set up- I work in a rural level 4 ER (small 9 bed). In our hosp we triage all OBs before they go to L&D unless they are a scheduled induction or section. If they are greater than 20 weeks with + ROM, vag bleeding, contractions or HTN we MUST call L&D and give report to a nurse and get an OK before bringing the pt to L&D. Today we got a call from the clerk for a w/c in the parking lot. One of the medics(in hosp EMS) and our ER tech went to get the pt. They came back in with a VERY pale BF, extremely diaphoretic and near syncopal( you know the look-eyes rolling back and head lolling). The medic looked at me and said we need to get this pt in a room NOW( I had already came to that conclusion). I pointed at a trauma room and he shook his head and said OB. I get her in the room( a gyn room) and notice this woman has lost ALOT of blood lady partslly and had clear fluid mixed in. During assessment I find out she is 7month OB. About 2 min in the room she is vomiting profusely. We get her on the bed she is tachy at 119, BP is 140/100 and sat 100%. While we are getting her in the bed I have sent for the ER doc. He checks her and she is not dilated, but she begins to moan and stated she is having sharp pelvic pain.( She is G2 P1.) no fht.get a line and have had her in the room 5 min when the OB doc gets there and asks WHY is she still in the ER. I told him that she Just got here 5 min ago and I felt that she was not stable enough for me to transport to L&D without attempting to stablize first. We got a line and called L&D gave report and transported her to L&D. She was in our er for a total of 13 min. The house super called me 30 min later to tell me the pt had to have emergency section for total abruptio and the baby did not make it. She asked how long the pt was in the ER( she was not trying to place blame just curious. I had called to ask about pt). I told her and seems the L&D had made some comments about me not bringing the pt to them immediately. I found out that they KNEW she was coming and had not seen fit to let anyone in the ER know. I feel I did what was right. I have been taught to stabilize mom first then worry about the baby. That was what I did. The ER doc agreed with me and I know he will back me up as well as my documentation. I just wanted some opinions on what you would have done. Thanks- BTW I absolutely HATE doing OB. I feel totally overwhelmed by having more than one pt in a body.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Okay this is kind of long but I would like your opinions on this. Let me give you a little set up- I work in a rural level 4 ER (small 9 bed). In our hosp we triage all OBs before they go to L&D unless they are a scheduled induction or section. If they are greater than 20 weeks with + ROM, vag bleeding, contractions or HTN we MUST call L&D and give report to a nurse and get an OK before bringing the pt to L&D. Today we got a call from the clerk for a w/c in the parking lot. One of the medics(in hosp EMS) and our ER tech went to get the pt. They came back in with a VERY pale BF, extremely diaphoretic and near syncopal( you know the look-eyes rolling back and head lolling). The medic looked at me and said we need to get this pt in a room NOW( I had already came to that conclusion). I pointed at a trauma room and he shook his head and said OB. I get her in the room( a gyn room) and notice this woman has lost ALOT of blood lady partslly and had clear fluid mixed in. During assessment I find out she is 7month OB. About 2 min in the room she is vomiting profusely. We get her on the bed she is tachy at 119, BP is 140/100 and sat 100%. While we are getting her in the bed I have sent for the ER doc. He checks her and she is not dilated, but she begins to moan and stated she is having sharp pelvic pain.( She is G2 P1.) no fht.get a line and have had her in the room 5 min when the OB doc gets there and asks WHY is she still in the ER. I told him that she Just got here 5 min ago and I felt that she was not stable enough for me to transport to L&D without attempting to stablize first. We got a line and called L&D gave report and transported her to L&D. She was in our er for a total of 13 min. The house super called me 30 min later to tell me the pt had to have emergency section for total abruptio and the baby did not make it. She asked how long the pt was in the ER( she was not trying to place blame just curious. I had called to ask about pt). I told her and seems the L&D had made some comments about me not bringing the pt to them immediately. I found out that they KNEW she was coming and had not seen fit to let anyone in the ER know. I feel I did what was right. I have been taught to stabilize mom first then worry about the baby. That was what I did. The ER doc agreed with me and I know he will back me up as well as my documentation. I just wanted some opinions on what you would have done. Thanks- BTW I absolutely HATE doing OB. I feel totally overwhelmed by having more than one pt in a body.

Sounds like to me you did the best you could do in a short amount of time. 13 minutes is not long.

I, too, know that small town, rural hospital thinking (being from the Deep South myself). The L&D dept. failed to apprise you of her arrival and that in itself is not right. I am sure there was a fetal demise prior to arrival. I think you should be commended on trying to stabilize this woman.

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Thanks SIRI. I don't have alot of OB experience( little to none lol). I can't think of anything I would have done differently. I understand how stressful it mest be for an L&D nurse to go through this senerio in their side but I don't want them to be blaming me for the fetal demise. Mostly I feel so bad for the mom. I WISH that there could have been SOMETHING I could have done to save her baby, but I know that there was nothing else I could have done without breaking policy at this hosp. I am glad to hear from someone with more experience on this subject like you. Again THANKS!

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I do think a patient like that should go straight to OB or someone from OB should come to ER. They are a lot faster and better at assessing OB patients and it seems silly to make you get all the history then have to waste time repeating it to them. But, if that isn't your hospital policy then they have no right to complain to you.

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Specializes in Emergency.

You pretty much did the right thing. About the only thing that might have saved the baby in this case would have been her being in the OR long before she presented to the ER.

On thing missed though is the shakey EMTLA ground that can come in to play. This pt presented to the ER and as such requires a medical screening exam and treatment for any emergent medical conditon found prior to being sent elsewhere ie L&D. There are exceptions to this rule that most hospitals have spelled out in their protocols. Every hospital I have worked ED in most the time sends pts past a certain point- it varies from 16-20 weeks-- directly there. Pts that are obviously in shock, as your pt was and any ER nurse with any experence can tell just by sight; with iminent delivery, or trauma generally get ED cleared first.

Rj:rolleyes:

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Thanks for the replies. I have an update. The L&D nurse manager called me today and told me that I did a good job with that pt. She said I did exactly what I was supposed to do in that situation. She also said she took care of the comments about the amount of time the pt was in the ER. I feel better about the situation today, don't want to got through anything like that again though. She said the mom was doing okaytoday and that the baby was probably gone long before they arrived in the ER. Still sad for the mom.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Thanks for the replies. I have an update. The L&D nurse manager called me today and told me that I did a good job with that pt. She said I did exactly what I was supposed to do in that situation. She also said she took care of the comments about the amount of time the pt was in the ER. I feel better about the situation today, don't want to got through anything like that again though. She said the mom was doing okaytoday and that the baby was probably gone long before they arrived in the ER. Still sad for the mom.

See, I told you that you were right on with the assessment.

Good job.

Always go with your gut feeling!!!!! I am very sorry about the baby, however. I knew a fetal demise had happened before presentation to the ED.

Hope you do not have anything like this for a while, but, now you know you can handle it.

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You really didn't even know she was pregnant until she was on the stretcher. At that point it makes sense to start a line, get vitals, make sure she is likely to survive the elevator ride up, and call OB. I think it behooves them to call you and tell you if they have an emergent patient coming that they want brought right up, or come down and assist until the pt is stable enough to move.

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Specializes in ER.

I think it sounds like you did fine...We would have done the same given the situation...The patient was unstable, we would have had OB come to the ER and then probably to the OR from there...If the baby had no fetal heart tones for you, chances are mom was already bleeding for a while and even if the baby went right to the OR the outcome may not have changed...We send every patient over 20 weeks with any abd complaints right over to L and D, however, if there water broke, we check for crowning prior to going over...so our Level 1 Trauma center would have played out the scenario the same way...Good job for doing the best you could!

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