Prolonged ROM and chorio

[RaeT,RN]

I had a pt today that I just cannot get out of my head. She was 34+2 weeks and had been ruptured for 6 days. Our High Risk Antepartum unit had been her home. Late last night around 0300 she spiked a temp of 101.4, so we got her around 0330 or 0400 for induction. Had been on PO abx the past week. Switched those to Clindamycin and Gent IV today for induction. My preceptor and I came on at 0700 and did not really get a full report from the night nurse because things happened so quickly. She and I worked as a team to get the pt an epidural because she was just sobbing uncontrollably with her contractions. I guess this was partly from her tender uterus? Once her epidural was in place, she was comfortable, and even kind of half asleep until she got to complete and +2, which happened very quickly. Screaming at me "when is this epidural going to work?!?!?!?!?" Maybe it got everything except that last dermatome? I try to explain to her that she still will feel pressure, but it should not be painful. She is really getting out of control and keeps saying, "I just want the pain to go away! When is this damn epidural going to work?" Doc is in the nursery doing a circ and takes him 15 min to get to the room. I am trying to get her to breathe, but she just keeps sobbing. The doc gets there, she pushes twice, screaming and sobbing the whole time, and baby comes out and does really well; Apgars 7/9.

Well, as you ladies know with chorio, her uterus clamps down on that placenta. Birth time was 0814, placenta time was 0835. And that was only after manual removal, during which she shreiked and screamed so badly that I had 3 other nurses besides my preceptor to come running in the room. She loses about 700cc, but doesn't bleed much after delivery; a golf-ball-sized clot about 30 min after delivery, but other than that your normal dark red bleeding. Once it is all over, I get her some breakfast. She denies pain, even with fundal massage. She sleeps for a little bit before I get her out to PP.

I felt so badly because I tried my hardest to be that calm, soothing presence, but she was not responding to me during the worst of it.

So, after this long-winded post, my questions are: Why would docs put pts on PO abx as opposed to IV when they are on Antepartum? Would the IV abx have put her at less risk for chorio? What percentage of babies born of mothers with chorio end up septic as opposed to those that do not? Is there a strong chance of mom getting septic herself, especially with that manual removal? How quickly would you see this?

[Jolie, BSN]

I feel for this woman, and commend you for trying to learn from her situation, and possibly help another patient avoid these complications.

I'm not currently in practice, so I don't know the current standards, but it does seem odd to me to have a hospitalized patient on po antibiotics rather than IV when she has such a high risk for infection.

Her baby clearly needs a septic work-up and at least 3 days of IV antibiotics.

Let us know how things go with this patient.

[JaneyW]

She might have been on IV abx and just switched to PO. She had been PPROMed for 6 days. That would make sense where I am. We have patients that stay ruptured for weeks and are only on IV abx periodically based on symptoms. If she had a manual extraction, she would be on IV abx for at least 24 hours postpartum. We usually do amp and gent.

I don't know much about treatment for the baby, but I'm pretty sure there will at least be a septic workup. That was a good learning experience for you. Labor is a powerful thing. We don't always have the ability to help people stay calm and you shouldn't feel bad about it. It doesn't mean you are a bad nurse. We don't really have control over others. We can do what we can, but you shouldn't take it personally.

OTOH, did they offer her additional meds for the extraction? Could she have had some morphine? Her epidural wasn't on or wasn't working at that point. Just a thought for next time. We don't have a separate antepartum--we are the antepartum. Will you be given some orientation on antepartum so you can see what they do?

[SmilingBluEyes]

I echo Jolie. Your desire to learn from this and your conscientiousness are to be commended. You did all you could do....chorio is a rough go for mom and baby. Why they gave PO antibiotic I can't say. Such a patient would be on IV gentamycin and ampicillin (if no allergies) from the get-go where I am---- if suspected of chorio. It's serious business. Let us know how things go.

[gypsyatheart]

I agree, she probably was on IV abx for anywhere from 48-96 hrs then switched to po to do a complete 2wk course. Once it was clear she wasn't imminently delivering it would be ok to do po. The majority of women who PPROM will get chorio at some point unless they go into labor. Then it is the game of stopping ctx's, while making sure there is no chorio starting. Eventually she's gonna go, from one or the other, or both! The abx usually suppress the organisms that will cause chorio....so we do "rounds" of abx on our long termers.

And, yeah, it does come on suddenly...one minute they are fine, the next they start w/the contractions, then they spike a temp and away we go! LOL! As for the babes, all of them should have a septic workup(CBC, blood cultures) done and be on at least a 48hr hold before going home.

Treatment practices vary, but that's about the gist of it.

[wannabeL&D73]

I had chorio with my 2nd, and baby was on IV abx while sepsis was ruled out. Thank goodness baby was not septic, b/c we had enough other complications to deal with. My first was also on IV abx b/c I was GBS+ and had a fever during labor. It sounds like you are a great nurse, and I can say at least for me personally, there are times when the pain is so great that it doesn't matter how calm, soothing, comforting etc. the nurse is. Glad baby is doing OK.

Shannon

[RaeT,RN]

Mom was allergic to PCN, so she was getting Gent and Clinda IV, which the doc continued until 24 hr after del. The Neonatologist came to see mom and said baby would be on abx for several days. Not sure how either are doing at this point. As the baby was 34 weeks, she is in our ICN and will be for a little while. Thanks for your responses - you all are a wonderful resource, and thanks for the support!