OB Emergencies

JentheRN05, RN · Aug 23, 2005

Okay, this is kind of long but I wanted some input on this. Let me give you some back ground. I work in a rural ER( level 4 and 9 beds). We triage all OB's that come in except scheduled inductions or scheduled sections. We call L&d if they are greater than 20 weeks with + ROM, vag bleeding, contractions, or HTN. We MUST give report to the L&D nurses and get an OK BEFORE we bring them to L&D. This afternoon we got a call from the ER clerk for a w/c in the parking lot. One of the medics and the ER tech went out with a w/c. The came back in with a VERY pale BF, extremely diaphoretic and near syncopal( eyes rolled back and head lolling). He said he needed a room NOW. I pointed at the trauma room and he said no OB We get her into the gyn room and I noticed that she had lost ALOT of blood lady partslly and there was clear fluid mixed in. While getting her into a gown and assessing her she begins to vomit and complain of sharp pelvic pain. I find out that she is G2P1 7month OB. While we are getting her in the bed I send for the ER doc. He checks her pelvicly while I get VS. She is not dilated but the blood IS lady partsl. VS tachy at 119. BP 140/100 sat 100%. We get a line and the OB shows up and asks WHy she is still in the ER. I told him she had just got there 5min ago and that I felt she was not stable enough for me to transport before getting vs and stablizing. He wants her in L&D so I call report and get her to L&D. She was in ER 13 min. I called the House super to get and update and she said she would callme. 30 min later she called and asked how long the pt was in the ER and I told her. She told me that the pt had gone for and emergency section. She had total abrutio and the baby had not made it. Apparently some of the staff in L&D had made some negative comments about me not bringing the pt immediately back to L&D. I was taught that we stabilize first and we treat mom first. I feel like I did what I could and was supposed to do but I would like your opinions about what you would have done. Thanks. BTW I am NOT an OB nurse I REALLY don't like OB very much at all. I like one pt in one body. I have all the respect for all the ob nurses. more power to ya.

I think that it's important for ER nurses to know the s/s of OB emergencies. In my opinion, only my opinion. If you knew what was going on, more than likely you would've taken her over sooner. She had the s/s. Not a knock on you personally, your job is very important, and one I couldn't do (I'm an OB nurse) but if you knew she was abrupting, you would know seconds count to save the baby.

I hope I never see that myself, I am new to nursing and that's one scenario that scares me.

ERNURSE4MS · Aug 23, 2005

Thanks for the input. I do know the signs of OB emergencies. I felt that the mom was in too much distress to transport her without stabiliztion. BTW I checked FHT immediately and could not find any ( probable fetal demise prior to arriving to the er). The thing that got me, though is that the L&D nurses KNEW she was coming and didn't call and let ER know. I was taught that if we don't stabilize the mom then the baby has NO chance at survival. She was only in the ER 13 min from door to door.

SmilingBluEyes · Aug 23, 2005

Seems to me, you did all you personally could. The ONLY thing I might have done differently was call and had an OB nurse dispatched to ED ASAP to help w/the situation. It IS indeed your priority to first stabilize *then* transport, and you did that----just as you should. I can't see REALLY where you could have done much differently. Abruptions are tricky, often-sudden and scary things, and they can go bad FAST, as you saw. You were treating the most emergent things----getting a line WAS critical. Getting O2 on mom, critical. Attempting to stabilize, critical. W/blood pressure like that, she could seize, as you know. It's clear she abrupted likely due to a case of uncontrolled gestational hypertension.

As I sit here and think, I really feel for you. What a terrible situation you were faced with---and the decisions you had to make, frightful.

I am not sure I can say what else you should have done differently---except get OB staff in there, if need be, to help out w/monitoring the mom/baby from their end. She was clearly VERY unstable and in severe trouble. I am thinking you did the best you could, faced with the horrendous emergency you were.

Were L/D personnel made aware this patient was there? That is my one question for now......if not, that is all I would say you should do differently. If they were, then they should/could have hightailed it down to HELP OUT (we do in cases like this). Other than OB, all the critical "players" were involved, the ED staff, the supe, the dr. What more can you DO in less than 30 minutes???! (13 to be exact, am I right?)

My advice: Try not to kick yourself too hard. There was nothing YOU PERSONALLY could do differently that would have impacted the outcome. You have what now? A LIVING mom right now who could be DEAD, if you had not acted quickly and seen to her most emergent needs.

My friend, you know you can't control what comes through your doors----in the case of a complete abruption, you have minutes, mere minutes---- from decision to incision---- to save the baby. It seems the dye was tragically cast when the lady hit your parking lot. It was a horrible thing---this is the horrible downside to what OB is all about. Outcomes like this, tragic and sometimes unavoidable, do happen, and it makes us all sick inside.

Seems to me, you did the very best you could with what you had. We can all sit here and "armchair quarterback" your movements and actions...and that is what the L/D staff are doing now. Nice they have that luxury. It's quite a different thing when it is WE who are dealing, now isn't it? So I say again, don't kick yourself so hard!

JentheRN05, RN · Aug 23, 2005

Thanks for the input. I do know the signs of OB emergencies. I felt that the mom was in too much distress to transport her without stabiliztion. BTW I checked FHT immediately and could not find any ( probable fetal demise prior to arriving to the er). The thing that got me, though is that the L&D nurses KNEW she was coming and didn't call and let ER know. I was taught that if we don't stabilize the mom then the baby has NO chance at survival. She was only in the ER 13 min from door to door.

Well - I have to agree with the other response. If only a L&D nurse was there, wouldn't been the only thing you could've changed, if the baby was gone, which is very possible when you aren't sure of how long all of this is going on, then the right thing to do was stabilize the mother. She would've died (possibly) if you had not.

Kudos to you for doing your best. I hope that my last response didn't upset you, as it was not my intent. I wasn't sure if you knew the s/s of abruption. I apologize. You did the right thing :chair:

ERNURSE4MS · Aug 23, 2005

Thanks for the posts. This was stressful for everyone involved. I have never see an abruptio before today, but had studied the s/sx in TNCC several times. There were several factors that were difficult here. One thing I haven't mentioned was that this was a larger woman. She was about 5'4" and about 250# so she did not LOOK pregnant. My thoughts on sight were-MI, CVA or some other MS traumas. I was not until my medic told me she was OB did an OB emergency come to mind. As soon as he said that my thoughts were to get her to L&D as fast as I could but I knew I had to stabilized her first. She LOOKED BAD. She had that look of someone who was going to crash FAST. I have been doing this long enough to trust my gut. The other thing was that when I assessed her abd, it didn't feel like the text describe. Beneath the layer of fat the uterus was rock hard ( not like a contraction-I know how those feel)and not at the station I expected. . It was 2-3 finger widths below belly button. I have always been taught you look for the entire abd to be ridgid not just the uterus.Things just didn't FEEL right. I found out later that this had started several hours earlier and the mom had delayed coming. Still my prayers are with her and her loss. I am thankful that SHE survived though.

jlamb · Aug 23, 2005

Thanks for the posts. This was stressful for everyone involved. I have never see an abruptio before today, but had studied the s/sx in TNCC several times. There were several factors that were difficult here. One thing I haven't mentioned was that this was a larger woman. She was about 5'4" and about 250# so she did not LOOK pregnant. My thoughts on sight were-MI, CVA or some other MS traumas. I was not until my medic told me she was OB did an OB emergency come to mind. As soon as he said that my thoughts were to get her to L&D as fast as I could but I knew I had to stabilized her first. She LOOKED BAD. She had that look of someone who was going to crash FAST. I have been doing this long enough to trust my gut. The other thing was that when I assessed her abd, it didn't feel like the text describe. Beneath the layer of fat the uterus was rock hard ( not like a contraction-I know how those feel)and not at the station I expected. . It was 2-3 finger widths below belly button. I have always been taught you look for the entire abd to be ridgid not just the uterus.Things just didn't FEEL right. I found out later that this had started several hours earlier and the mom had delayed coming. Still my prayers are with her and her loss. I am thankful that SHE survived though.

I think you did what you knew to do. If the Labor and Delievery department knew she was on her way in, they share culpability. One of the more experienced OB nurses, or the director, whoever, should have been waiting in the ER for her. As a CLNC, I would want to know why they were not present. You held to the standard of care, stabilize and transport. The patient also should not have waited to come in. She obviously didn't take care of herself or she wouldn't be 5'4" and 250 pounds. I don't mean to sound unsympathetic, I have had 4 children die myself, but she should have come in sooner, the ER doctor should have been made aware she was on her way in, the OB nurse should have been present at arrival, and an OB doctor should have been notified. How did OB know she was on her way? A rock hard uterus is a sign of abruptio. In the hospital I work in, if an abruptio patient comes in, they are often automatically taken to the surgery holding room with an OB nurse and anesthesiologist, accompanied by an ER nurse, but the patient doesn't stop in ER, they go straight into the surgical suite.

All in all, I think you did well, especially since you were not privy to full information.

jeepgirl, LPN, NP · Aug 23, 2005

abruption.

you gotta move very fast to make sure mom / baby is ok... that is probably why he was all up in your business. but, you did what you could do. you had to stabilize first.

NurseLatteDNP, MSN, DNP, RN · Aug 23, 2005

She obviously didn't take care of herself or she wouldn't be 5'4" and 250 pounds.

Oooooh, what a harsh judgment!!! :nono:

rn/writer, RN · Aug 23, 2005

Rock hard uterus. Mom delayed coming in for several hours. I'm guessing that baby was gone before they hit the parking lot.

Even a crash c-section takes a few minutes to set up. They have to get lines in, especially with a mom who is already bleeding out. But, as I said, this sounds like a case where an OB waiting, scalpel in hand, as the mom opened the car door, wouldn't have saved the wee mite.

As for the harsh reaction, consider this. When people experience a real fright, when they feel terrible about what happened and frustrated that they couldn't change the outcome, it is human nature to convert all that fear and helplessness to the much more "in control" emotion of anger. It isn't right. And perhaps when the dust settles, reason will prevail and you can all talk productively about what happened that terrible night and what might happen should this situation arise again (I hope it doesn't). But in the heat of the moment, it is not at all uncommon for those who are used to being in charge to hide an entire collection of emotions behind anger which seems ever so much more powerful than being scared and sad.

I would advise you to write a detailed account of your part in this event and keep it in a safe place. Add things as you recall them. And then when you are fairly certain you have it all down on paper, type it up and keep the nice copy and all of your notes for future reference. It doesn't sound like the mom has any kind of claim as she is the one who put off coming in, but

you will have your ducks in a row if you are ever questioned. Not to mention that putting all of this into words can be quite cathartic.

One more time, it really sounds like that baby was gone before they ever showed up.

Be good to yourself.

Miranda

CrunchRN, ADN, RN · Aug 23, 2005

You did everything you could and should, and other team members (OB) are the ones that did not respond appropriately. That said - these things are impossible to diagnose over the phone and I am sure no one was aware how critical the situation was. A sad situation, but you were an excellent nurse and hopefully this can be a learning tool and a plan can be set up ahead of time for any possible repeat situations.

SmilingBluEyes · Aug 23, 2005

Well gee, 13 minutes from door to OR. I dunno, can't say we would have done it quicker.

I say you did very well---there was no way to save the baby at that point. Like I said, you have a living mom who admittedly, lost a lot, but she is ALIVE due to your quick-thinking and actions. Please pat yourself on the back for that.

And quit letting the L/D folks get to you. I can't imagine they could have saved the baby either! THIRTEEN MINUTES-----good work!