Thursday, October 30, 2008

29 Week Cervidil X2?

I apologize ahead of time if I miss totally obvious reasoning for why this happened, but to me it just didn't make sense...

G1 29weeks presents to L&D sometime Monday afternoon for higher blood pressures and just not "feeling right." Her mom used to be a nurse in an OB's office, so of course Grandma knows "exactly" what is going on...anyway, her pressures weren't pretty (150's/100's consistently) but since it was a busy day in the office, her doc wanted us to just watch her and treat her pressures with labatalol. Her urine was dipping 4+ protein and you could tell there was some swelling going on. Labs came back "ok" not fantastic, so doc ordered a 24-hour urine to check protein, etc. So that buys her at least a 24-hour stay. She got her first dose of steroids for fetal lung development and hung out 'till Tuesday afternoon.

Tuesday, her pressures are even worse and her 24-hour urine came back with 6 GRAMS of protein. That's a lot of protein!!! The nurse had her mag set up and ready to go, but of course it was busy in the office again and it was after 1600 before a doc had a chance to come over and actually see her. She got her 2nd dose of steroids and herr 4gm mag bolus got started late Tuesday afternoon, and then the doc decides that maybe she should be delivered sometime in the future, so they order a cervidil, with mag going on a closed, thick, high 29-week primip who had a recent LEEP procedure and has tons of scar tissue. Ok...

Wednesday J and I took over. She was still closed tight, thick as anything and way, way, way, way posterior after 12hrs of cervidil. The doc that was just walking off of being on call that night didn't order pit, didn't order a c/s for this girl who's labs were continuing to get worse, no, she ordered a SECOND cervidil. Why, why, why, why? She's 29 weeks and has had a LEEP! She's on mag which STOPS contractions, and you want a cervidil? A cervidil isn't gonna do crap!!! But the doc was going off call wanted it put in, so I put it in. The next on-call doc came over and said let's see what's happened after we draw more labs and check you about 1400, after the second cervidil has been in for 6 hours and see what happens.

So for the first 7 hours of my shift, I try to talk to the poor patient who is in a Mag fog and can't concentrate and feels horrible. Like having the flu without having the flu, just nasty from the mag. Every hour check breath sounds, empty the foley bag, check reflexes and clonus and give her her 30cc of sprite. Between the hourly checks, watch a monitor with two totally flat lines running across them: one being a completely mag'd out 29 week baby and the other being a uterus that is as quiet as my non-pregnancy uterus.

1400...uric acid level has gone up from 6.5 to 7.9, platelets and liver enzymes aren't great but still "ok" for PIH, pressures are still 140's/high 90's and guess what, she's still closed, thick and high. Absolutely no change, but not surprising since she's not had ONE contraction! The doc on call wanted to know if he could come over and AROM...no he couldn't.

Can we take out the cervidil and please do a section on this girl who's getting sicker before our eyes? No, the SECOND cervidil has only been in for 7-8 hours, you know the last 4 is going to change a closed/thick/high 29 week cervix that hasn't changed in the last 20 hours of cervidil. So, after the pager has been passed through two more docs, finally the nigh on-call doc comes over at J's pleading, checks her, and guess what?! She's STILL closed, thick and high! We've had to turn her mag down because she's getting toxic and baby is still a straight line across the monitor screen.

So about 2000 last night this gal gets cut, baby ways just under 1000g, but came out screaming I guess. Mom's back on l&D for at least another 24-hours on mag and I'm guessing baby's been shipped to the big children's hospital across town. The moral of the story is that this gal was sick and she wasn't getting ANY better just sitting there. What do I know, I'm just the nurse, but it seemed to me that no doc really wanted to take over and say "look, this is what needs to happen, and I'll do it." They all wanted the NEXT person in line to have to deal with it. I know it's not convenient, and I know it's a big responsibility, and I know it takes time away from the office, but what's more important, the office or a sick patient in the hospital. I don't know, I'm just the nurse.

I guess it was a crazy night on L&D, right after that 29 week section happened, the same doc that delivered a VBAC and everyone thought that baby was a girl, and it showed up with ambiguous genitalia. All the excitement and I'm already gone and didn't get to see any of it! Is it wrong to be disappointed in that?

4 comments:

  1. Most of our docs would have bought her a little more time with the steroid shots, and then did the c-section. NONE of our docs would have even tried to induce a 29 weeker!

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  2. Oh my...I am glad I wasn't the pt that is all I can say. I wonder if the lady will have anymore children after that one. It is crazy because some people have very easy labors and others have horrible ones. I can't believe the cervadil didn't work out of 2x. That baby didn't want to pop out..... 29 weeks is early! Great story!!

    Sarah ;-)

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  3. That happened to me, except at 36 weeks and I ended up delivering vaginally. Presented to the office with pressures of 160/120 and dipped 4+ for protein. Was totally swollen. Had upper right epigatric pain for almost 2 weeks (acute care clinic on base said it was indigestion). Headaches off and on and visual changes. Admitted to the hospital immediately for observation. Next day assessment started with a 24 hour urine, labs, NST, US, etc. 24 hour came back 5250mg protein, GAINED weight overnight (2 lbs I think), urine output low, crappy labs (liver enzymes high, uric acid was 18.6, LDH was 685, bad labs). They decided to send me to L&D and induce. Was not started on mag yet. They did the first dose of gel at 8pm. At midnight, I got really sick. THE HEADACHE, bad reflexes. Started on 6 gram bolus of mag. At 3am they checked me, nothing going on. Second dose of gel. All checks were excruciating as the midwife had terribly long fingernails. My cervix was thick, long, closed, and very very posterior. Oh and I puked nonstop on mag. At 9am was checked again. Nothing. At that point, I was sick of being sick and demanded a csection. (This was all in a hospital in Belgium at the time, we were military stationed overseas). Chief of ob came in and saw me and said that they couldn't do a csection at that point. That I would either seize/stroke out and/or bleed out on the OR table. He had one more thing he could do that would definitely work. FOLEY INDUCTION. I will never ever ever ever ever agree to that again. A foley pushed into a very unripe closed cervix without pain meds was the worst pain I had ever experienced. Afterwards they gave me stadol and fentanyl to sleep. It worked. They started labor at 4 pm. I had an epidural before they started labor with pit. I delivered at 11pm. I went from 5 to 10 cms in one contraction at 1030pm.

    I am currently pregnant again. I had a doppler blood flow study done at almost 18 weeks 6 days at my peri's office. It showed notching on the right uterine artery. My peri told me I will get sick again with pe. She doesn't know when or how bad. She is guessing around the 35 week mark. My ob says I am very high risk for it.

    I have already decided I will never ever agree to what happened with my first daughter. My second daughter was an emergency induction for PIH (no protein on day of delivery). My ob just used pit and it put me right into labor at 35 weeks. If I get as sick as I did with my first and Ih ave a stubborn cervix. Cut me open doc.

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