Please! i need your expertise on this.

Specialties Ob/Gyn

Published

im very new in L&D and i would really appreciate your hindsights on these scenario.

A G2P1(now P2) came in LnD for sched induction. While on EFM, pt was saying that she was not comfortable being induced and felt like it is being done for convenience and would rather wait for nature to take its course. But the only Obstetrician is going away for 4 days and so are the other doctors who do the C-section. That left no choice for the OB but to have her induced that day or the next day or take the risk of having a Fam Physician deliver the baby and drive/fly her on the next city which is an hour away (or 1.5-2 hrs depending on the road condition) if something bad occur.

Her hesitancy with the induction and the OB reason for inducing her lies with her previous L&D which was 2 yrs ago. She said she labor for almost 2 days, induced with gel 3x and with Oxytocin as well but the progress was poor. In the end the baby was delivered with shoulder dystocia.

Now- after discussing her concern, the risk and everything she agreed to have the induction. Prior to this she was emotional about it but eventually able to accept why it is needed and she was cheerful and back to her normal self again.

1330= Prostaglndin 0.5 inserted

1700 = cervix 4-5cm, AROM done.

1930= change of shift

1945= 8cm; demerol + gravol given

(in between mom walking the hallway, up to warm shower, FHR very reassuring the whole time, lots of accel & and with fetal movements, no decel)

2012= baby delivered.

baby pink, good heart rate but no respi effort for 20 mins. baby was put in isolette and was on antibiotics for 3-4 days. APGAR 4-5-6/7

Later on GBS was found positive. Which i believe should have been handled on my shift. I told my senior nurse that GBS was done, pt does not know of the result and not written on the antepartum either. I felt responsible on this coz i should have been more aggressive on getting the GBS result thru my senior RN since i dont have the access with lab works/UTZ yet. but since she was not bothered by knowing the result, i did not bother with it too but i know that I really MUST HAVE!

Baby was perfectly normal, no symptoms of anything is wrong. but we will never really know until few years later right?

1. Could it be the Demerol? which was given less than 30 mins before the babys delivery?

2. or the GBS? which i personally feel responsible for.:o

I just feel so bad, i should always listen with my instinc. I havent been anywhere but OR for my entire nursing carrer until now.

The doctors dont know the explaination for this either.

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Specializes in ob; nicu.

could be a combination of both. we always tx a pt. as if they are gbs+ even if we don't have a definitive result. the results of the baby's blood culture would have determined that. demerol can most definatley make the baby unwilling to cooperate, but i guess you will never know exactly what the deal was. just know you learned from your mistakes and will anticipate that all of the babies can be sick, no matter what the efm or the uncomplicated prenatal history. good luck. and when all else fails, go with your gut.

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Specializes in Community, OB, Nursery.

Where I am if Mom is GBS+ but was not treated adequately (for whatever reason), baby gets blood cultures automatically, but not abx unless the culture comes back +.

Demerol is notorious for causing neonatal resp depression, especially that close to delivery; that's part of why we don't use it anymore! Is that something commonly used in labor at your hospital?

I wouldn't beat myself up about it if I were you. If I had to pin it on something, just knowing what you've posted here, I'd be willing to bet it was the Demerol given so close to delivery. You learned a few things. You'll know better what to do next time. You'll know what pieces of information you need, and how to go about getting them. You'll know what to expect at the next similar delivery.

Just out of curiosity, how many weeks was this patient?

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Specializes in ob; nicu.

Our babies get cbc's and blood cultures if mom's abx had not been infused for at least 4 hours, and depending on the cbc and I:T, we many times go ahead and treat our kids before the culture returns. Oh, and we usually use stadol at our facility.

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Specializes in Community, OB, Nursery.

Nubain and Fentanyl here. I'm not crazy about them, either. Those kids are either shrieking or apneic!

Edited to add - the stuff I'm referring to applies to well-baby nsy. NICU is a whole different ballgame.

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they did blood culture right after and it turned out negative.. thanks heaven!

and yes - Demerol is very much in constant use for pain management. I see this more often than fentanyl actually.

they did ABG on the cord blood which turned out 7.12 - but i think the cord blood was drawn 25mins after delivery. Capillary ABG came out normal.

I love working in OB now, but i miss the peace of mind of working in the Operating Room.

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Specializes in Midwifery.

As someone said don't beat yourself up over this. Early onset GBS disease is actually quite rare, even in women who aren't treated in labour. I think the stats are that around 1-2% of kids born to GBS positive mothers who aren't given labour antibiotics will get EOGBSD. This kid sounds to me like it didn't have GBS, but they were just being cautious with the low apgars and GBS +ve mother. Been along time since i did SCN but a kid with proven EOGBSD would be on abs longer that 3 or 4 days. Some babes are born flat by surprise! Do you know whether a GBS infection was proven?

Some other things to think about...was there a tight nuchal cord? Did the kid come down really quick in the second stage? What was the CTG like?

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ACOG does not recommend treating for unknown GBS status (unless a prior child had a hx of sepsis, I believe; or mom has been ruptured >18 hours).

I'll bet it was the narcotic prior to delivery.

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Specializes in Midwifery.
ACOG does not recommend treating for unknown GBS status (unless a prior child had a hx of sepsis, I believe; or mom has been ruptured >18 hours).

I'll bet it was the narcotic prior to delivery.

Nor does the CDC or the RCOG and a list of many others. Giving antibiotics to a women who is unknown GBS is overkill at best and really poor practice at worst. There is more and more research coming out about the effects of antibiotics on children under a year and asthma and allergies. We do not know the long term effects of giving intrapartum antibiotics, and because we have to give 600 GBS postive women antibiotics to stop 1 case of EOGBSD; why bother giving it to those who don't need it! Sorry......alittle bugbear of mine!!!

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Just to be the devils advocate here-- even if you *know* a woman's GBS status, your really don't! Someone can become GBS positive after the test is complete.

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My money is on the Demerol.

Was Narcan given at delivery or afterward? Sounds like it should have been if it wasn't.

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Specializes in Midwifery.
Just to be the devils advocate here-- even if you *know* a woman's GBS status, your really don't! Someone can become GBS positive after the test is complete.

Yep but if shes had a swab within five weeks of the birth there is only a miniscule chance of her becoming GBS positive when that swab was negative. And when you consider how FEW babies actually get GBS infections...its all overkill really. Are you advocating giving women with an unknown status ABs? Am serioulsy interested in this stuff....its fascintating when you start number crunching .......

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