22 weeks on a cardiac floor.

[raskol]

I had a question regarding fetal heart tones.

I work on a cardiac step-down floor (our population is most commonly cardiovascular surgical patients) however the other day I had a 30 y/o female patient admitted with chest pain. However, she was 22 weeks pregnant. The only real treatment I was giving (all her cardiac workup was negative) was dilaudid 0.5mg IV q4.

I called the resident.. as I was concerned at this choice of pain medication, as well as the fact her OBGYN had not been consulted and I could not monitor heart tones. (I have a vascular doppler. but it stated not for fetal heart tones.. and I think I only picked up mother's heart rate (100s)).

After jumping the ladder, I finally got them to switch to stadol and they said it wasn't a big deal if I don't get heart tones. The attending the next morning said at 22 weeks monitoring heart tones is unnecessary since the fetus is non-viable at this time..

ANYWAYS.. my question is, as the experts in maternity,.. is it appropriate to not monitor heart tones, and was I right to be concerned about the dilaudid? I just want some guidance since at my dedicated heart hospital none of us nurses have experience with this population and we were at a loss at what to do with this patient.

Thanks.

[merlee]

The fetus isn't viable?? That is a poor choice of reasons/rationale.

BTW - - just yesterday, an 8 yr old boy did the coin toss at the Colts game. He was a 22 week gestation baby at Riley Hospital, here in Indy.

Tell that doc he better get up-to-date.

And I thought you meant you were working or hospitalized on a cardiac floor for 22 weeks!!!!

[MKS8806]

We had a 17 weeker on our floor the other day (OB floor) and we dopplered heart tones once a shift and prn per pt request - she was miscarrying. We usually don't see pt's on our floor unless they are 20 weeks or more, but this one was an exception. My point though, is that there should be some monitoring guidelines for pts at least 20 weeks or more....If its not an OB issue, we generally monitor q4-q8hrs depending on how far along they are.

[birdie22]

We had a patient in their early 20s, 28 weeks pregnant in the hospital for crohn's. She was getting 0.4 dilaudid q4hrs. She was getting around the clock, and was in the hospital for about a month. Not to mentions she needed TPN, had developed an abscess, and had a colostomy due to the crohn's complication. Talk about a hard pregnancy! From what I remember with OB part, since we werent an OB floor (or a cardiac floor) the OB team would come like every other day and check up on the baby.

We would all question the dilaudid order and the covering MD team kept on telling us 'well the OB docs said the dilaudid was ok, so just give it' and stuff like that. I believe she was in true pain. Eventually we got it knocked down to 0.2mg q2hrs. Also I remember one of docs mentioning that they werent so concerned because the due date wasnt exactly around the corner.

[SeeTheMoon]

Not viable huh?

Let him try explaining that to the mother carrying.

[Anna Flaxis, BSN, RN]

Not an OB nurse, but here is what I do know:

Dilaudid: At that dose, for short term use, and early in pregnancy, I think the risks to the fetus are pretty low.

FHTs: In the absence of pelvic/low back discomfort and/or lady partsl bleeding, I can understand why the attending might not think FHT monitoring is necessary if the patient was to be admitted for observation for a short duration. However, you do not need a doctor's order to check FHTs. If you do not have access to a fetal doppler, you could try listening with your stethoscope, though it may be difficult to hear anything that early.

[turnforthenurse, MSN, NP]

From what I learned, a fetus is considered viable after 20 weeks. But I totally agree with SeeTheMoon's comment. :/

I also would have questioned Dilaudid.

[babyktchr, BSN, RN]

Dilaudid is fine to give. This patient should have had OB consult and orders for fetal heart tones. At 22 weeks, you definitely can find them with the proper doppler. I have gone to many a med/surg floor to get fetal heart tones on patients who need.

Being non viable doesn't mean that you don't care for the fetus. Shame on that resident for his/her answer.

[Anna Flaxis, BSN, RN]

I just want some guidance since at my dedicated heart hospital none of us nurses have experience with this population and we were at a loss at what to do with this patient.

Thanks.

babyktchr, I may be wrong, but it looks like the OP's facility does not have an OB/L&D unit, else I certainly would have suggested calling the L&D floor and asking for someone to bring a fetal doppler and do FHTs. There may not even be a fetal doppler anywhere inside the entire facility.

In the absence of that resource, what would you then suggest? I'm not trying to be a smart alec, I seriously want to know.

[Rob72, ASN, RN]

The attending the next morning said at 22 weeks monitoring heart tones is unnecessary since the fetus is non-viable at this time..

Yeah, it is sad. Some even make it through med school in non-viable condition...

[SeeTheMoon]

Yeah, it is sad. Some even make it through med school in non-viable condition...

BAHAHAHA!! Amen to that!

[babyktchr, BSN, RN]

Stargazer, I did not get that from the OP. She mentioned that her OB had not been consulted, not that they did not have L&D. Even if that were the case, any ED SHOULD have the appropriate doppler, since they should be able to ausculatate early pregnancies. I would certainly look to borrow theirs to check fetal heart tones. If there truly was no way to assess fetal status, then an ultrasound may be in order. Good question!!