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.

[raskol]

Yeah, we don't have L&D. The hospital had different campus and mother&baby is on the other side of town.

We did try the ED, waited half hour to borrow their doppler...they won't loan it for whatever reason. When I took report from the ED, the nurse stated she got heart tones but not a rate, because she would lose it before she finished counting.

They also had abdominal/pelvic ultrasound ordered. AGAIN my hospital, for whatever reason, won't do pelvis u/s on pregnant women... and by the time I got that cancelled, her abdominal u/s got moved to the morning.

The mother kept stating she could feel the baby kick.. so I pretty much went on that.

[Anna Flaxis, BSN, RN]

Thanks, OP, for coming back and giving further detail.

I could be wrong, but my guess is that a pelvic US on a woman at 22 weeks would be inappropriate because the uterus would be higher up in the abdomen at that stage of pregnancy.

Clearly, from your description, there was no reason to believe that any emergent medical condition concerning the fetus existed. The mother denied any abdominal cramping or lady partsl bleeding and could feel fetal movements. Therefore, it would be perfectly okay to do the US in the morning.

Yes, it would have been ideal to have had access to a fetal doppler and to have been able to do FHTs q shift/q day/q whatever frequency, but in the absence of that resource, I think that documenting the absence of any s/s of miscarriage as well as the mother's report of fetal movements, would be the prudent thing to do.

Maybe you could talk to your manager about the situation and suggest that the hospital purchase a fetal doppler for inpatient use. If the ED has only one fetal doppler, I can understand why they might be hesitant to loan it out.

[Penelope_Pitstop, BSN, RN]

I'm on a MedSurg floor, and we just discharged a woman who is 22 weeks pregnant.

FHTs were ordered to be auscultated Q4.

I believe L & D nurses came to do this, or maybe OB residents. We do have a large OB center in house which includes High Risk Maternity and a Level III NICU, so maybe since we have resources available we used them?

For a second I thought maybe you and I worked on the same floor until I read your followup post!

[RNLaborNurse4U]

22 weeks is iffy. 23-24 weeks is viability. To be honest, we would not resuscitate any baby under 23 weeks. 23 1/7 to 23 6/7 weeks (must have FIRM dates to determine this) is the very gray area of viability. (And I work in a level 3 nicu facility.)

No OB reason to do FHT checks on the 22 weeker as stated above. She wasn't having an obstetrical complication, it was a medical complication. However, one of us in L&D would probably auscultate FHT once per day for maternal state of mind.

The true issue is this: if you are doing something (listening for FHT), what would your intervention be if you found something abnormal (i.e. decel, or no FHT detected)? Stat c/section? I think that the doctor's rationale for no FHT checks is simply that you would NOT intervene for fetal reasons.

22 weeks = no resuscitation.

[RNLaborNurse4U]

And just FYI - we HAVE stat sectioned women who were abrupting, and were thought to be 24+ weeks, but then when the infant is delivered, it physically measures to be 22-23 weeks or less. How awful is that? A stat c-section under general, and the baby dies anyway because it is not viable?

[Penelope_Pitstop, BSN, RN]

22 weeks is iffy. 23-24 weeks is viability. To be honest, we would not resuscitate any baby under 23 weeks. 23 1/7 to 23 6/7 weeks (must have FIRM dates to determine this) is the very gray area of viability. (And I work in a level 3 nicu facility.)

No OB reason to do FHT checks on the 22 weeker as stated above. She wasn't having an obstetrical complication, it was a medical complication. However, one of us in L&D would probably auscultate FHT once per day for maternal state of mind.

The true issue is this: if you are doing something (listening for FHT), what would your intervention be if you found something abnormal (i.e. decel, or no FHT detected)? Stat c/section? I think that the doctor's rationale for no FHT checks is simply that you would NOT intervene for fetal reasons.

22 weeks = no resuscitation.

For our patient, I'm not certain how sure of her dates we were. She was also an IV heroin abuser.