Terminations vs Fetal Demises

KellNY, RN · Jul 21, 2007

why are they doing 1st trimester top in the hospital and not outpatient?

SmilingBluEyes · Jul 21, 2007

I cannot speak for 1st trimester terminations, as we would never see them. These in most places, are usually carried out on a day surgery type basis.

Other such terminations should be (and where I have worked, were) treated like induction for labor and the patients given every opportunity for pain management any laboring would be, including epidurals or IV pain meds.

In my experience, the folks experiencing terminations/inductions by cytotec progress rather rapidly, if unpredictably, so if they can't feel what is going on, monitoring cervical status is a good idea.

Hope this helps.

Jo Dirt · Jul 21, 2007

I don't understand, what if a mom was 21 or 22 weeks and her water broke, couldn't they try to save the baby? Couldn't they keep her in the bed in as sterile and environment as possible for as long as possible?

If I were in that situation I don't believe I could agree to allow them to kill it, would I be rejected as a noncompliant patient, or would they try to help?

mommyRN07 · Jul 21, 2007

I don't understand, what if a mom was 21 or 22 weeks and her water broke, couldn't they try to save the baby? Couldn't they keep her in the bed in as sterile and environment as possible for as long as possible?
If I were in that situation I don't believe I could agree to allow them to kill it, would I be rejected as a noncompliant patient, or would they try to help?

If a mom is 21-22 weeks with PROM, they can try to do that, and sometimes they are able to prolong the pregnancy to a more viable point. However, there is the risk of infection, and at that point, they have to induce. It's not necessarily "killing it" although obviously there isn't a chance of survival at that point.

crysobrn · Jul 21, 2007

We had a patient that was 21wks with twins and had a PPROM... I can't remember all the details but the hospital that we normally transfer our pretermers to refused to accept her because "it wasn't a viable pregnancy" they said they would accept her if she were 24 wks... SO, she stayed in our facility for a few days and did not want to do any induction techniques... the doc decided to let her go home as long as there was no sign of infection he'd transfer her at 24 wks. BUT she came back after about a week and delivered both twins. It was sad. They were born alive but died maybe an hour later.

I would hate to have to be that mom. I was so frustrated with the whole process I thought that if I were her I'd simply drive to the other hospital and arrive at their doorstep and say "here I am, please help me" I'm not sure if something could be done to help her because, thank God I don't deal with this a lot. I guess we did what we could.

We don't do any sort of "terminations" anywhere in our whole county. The resources are not there. If that is requested or needed, the patients are referred to larger hospitals/clinics or whatever.

When we have done inductions for demises, the patients that I've taken care of were very uncomfortable, they were provided with pain meds as in labor. We also do vag exams as needed. It's still strange for me to do a demise delivery because I feel like I should be doing more (checking heartones etc)Our docs rarely actually make it for those that are not full term... so we are there with a baby and a mom and family to deal with. The whole thing is sad and for a long time was very scary to me.

mommyRN07 · Jul 21, 2007

The docs don't go? That's not very nice. I know they can't help the baby but that's kind of stinky for the mom, who is also a patient. I would feel abandoned if that were me. Of course, I always saw Nurse-midwives, who would DEFINITELY attend a 'birth.'

I don't work in L&D, however, I know the hospitals here try to rotate staff so that the nurses don't get too many demises in a row. It must be very sad.

crysobrn · Jul 21, 2007

Well most of the time they can't make it because it just happens very fast. We don't have residents or interns... just the two OB's and they have office and need to be home etc. The last one that I did the doc wasn't even going to come in til morning (it happened at 9pm) but the mom had a retained placenta and ended up going to the OR.

SmilingBluEyes · Jul 21, 2007

These deliveries should always be attended by a qualified MD or Advanced NP/MW, just as any other would be. I can't believe any place allows anything less. However, I am thinking that most attempt to have this happen.

Yes, these deliveries go fast, but a dr/midwife should always be called in to evaluate the patient and her medical condition, to be sure all is well. I assume that is what most places do, even if the dr is not at the actual birth him or herself.

NurseNora, BSN, RN · Jul 25, 2007

On our unit, we are able to choose to participate as the RN, in either terminations or fetal demises. The vast majorities of our terminations are usually in their 1st trimester and the fetus has incompatibilities with life. I am fairly new to L/D and have never participated in either case as the main RN...I know it is a personal opinion, but what is the usual plan of care for these patients in your units?? I know it usually depends on the patients' presenting complaints, term, etc. We do use cytotec on our unit ONLY for terminations...Are terminations usually given the chance for an epidural?? Are you still regularly checking cervical status until they are complete, or only when they have the urge?? thanks all

The hospital where I now work does not do terminations of any sort. But we do use Cytotec for term inductions.

In other facilities, where I did work with some 2nd trimester terminations, the mother was treated pretty much like someone delivering prematurely or having a spontaneous ab. She was offered lots of pain relief (often more than would normally be given to someone expecting to deliver a viable baby) including epidural.

Yes, cervical status is checked regularly, but an early midtrimester cervix dilates differently than a term cervix. It feels different. Often the internal os dilates first, so that effacement seems to take place from the inside out rather than the other way. It often feels like a funnel. They often stay 2 cm until all at once they deliver. Early midtrimester deliveries are very frequently breech or even transverse. If they are breech, usually the head will be stuck in the cervix--for a long time. I will often sit the mother on a bedpan to let gravity help the cervix to dilate the rest of the way. And Mom doesn't have to lie there feeling her baby's body between her legs.

I ask the mother if she wants to see and or hold her infant, just as I would if it were a spontaneous midtrimester miscarriage. Just because a woman has chosen to terminate a pregnancy with a child with a condition that is incompatable with life, doesn't mean that she doesn't love the child (OK, so you wouldn't choose to show your love in this way. It's her choice. We're supposed to be nonjudgemental) or need to grieve the loss. If there is an anomaly of some sort, and she wants to see the baby, I ask if she knows what it will look like (eg anacephalic) and if not, I'll try to prepare her in advance about the physical appearance.

When the baby is born, if she wants to see it, I point out what looks normal. Anacephalics are not pretty babies; even if you put a hat on it, it still usually has a large protruding tongue and buldging eyes. But they almost always have perfect little tiny hands and feet. I'll usually do a breavement pack, just like for a spontaneous stillborn. If mom doesn't want to see or hold the baby, I assure her that she can change her mind later. Some do.

NurseNora, BSN, RN · Jul 25, 2007

I don't understand, what if a mom was 21 or 22 weeks and her water broke, couldn't they try to save the baby? Couldn't they keep her in the bed in as sterile and environment as possible for as long as possible?
If I were in that situation I don't believe I could agree to allow them to kill it, would I be rejected as a noncompliant patient, or would they try to help?

If a woman ruptures membranes at 21 or 22 weeks, there is a very high incidence of infection as it is often an infection that weakened the membranes and caused the PROM in the first place. Another problem with early PROM is that very often the resulting oligohydramnios does not allow the fetal lungs to develop properly. So even is the pregnancy is carried to viability, the baby can't breath when it is born. The fetus makes practice breathing movements in utero and the small flow of amniotic fluid thru the lungs during this is important in their development. Usually these babies are born with hypoplastic lungs.

It is your body and your baby. In the tertiary centers where I have worked, the perinatologist and the neonatologist would talk with you and give you specific statistics (specific to the institution and specific to their practice) as to the likelyhood of the baby living and an idea of the quality of life to be expected if the baby did survive. But none of them that I worked with would make the decision for you. If you chose to keep the pregnancy and pray for the best outcome, the ones I worked with would support you in your decision.