- Email: [email protected]
A Challenging Birth Experience
Driving home that evening, I reflected on all that had happened with Christina. So many things could have gone wrong, yet everything went smoothly
Laura Hubley, RNC, BSN CN III, is a nurse at Southern New Hampshire Medical Center in Nashua, NH. Address correspondence to: LauraAnnHubley@msn. com. DOI: 10.1111/j.1751-486X.2010.01513.x
86
coordinator to page the physician, resident and anesthesiologist, and to contact admitting, the lab and the neonatal intensive care unit (NICU). I reassigned the postpartum patient to a different nurse and directed another nurse to get the intravenous tray and fluids. The on-call physician arrived almost immediately. The fetal heart tracing showed a rate of 90 to 100 with minimal variability and a contraction pattern that suggested tetany. The doctor explained to Christina that most likely her placenta was beginning to separate from the wall of the uterus and she needed an immediate cesarean section to maximize the baby’s chance for survival. She started to cry while still coping with her physical pain. The obstetrician explained to her that she would need general anesthesia so that he could deliver the baby as quickly as possible. Her tear-filled eyes caught mine and I knew she was scared. Her nurse and I tried to reassure her by speaking calmly and explaining everything we were doing, even though it was all happening so rapidly. Christina’s husband was at work and she hadn’t been able to contact him before the ambulance picked her up. I assured her that our unit coordinator would do everything she could to try to get in touch with him. I told her who I was and offered to stay with her until he arrived. She was quickly prepped for the operating room. Routine procedures seemed to be accomplished within seconds. I started a second IV line in the operating room as the anesthesiologist prepared to intubate. The “time out” was called swiftly, accurately and loudly for all to hear. We heard the fetal heart tones seconds before the drapes went on. A slowing fetal heart rate intensified the atmosphere of urgency. I held Christina’s hand, feeling helpless at that point, but marveling at the calm, focused attention of the team moving swiftly about the room preparing for the delivery. The scrub nurse had the table neatly prepared with the stat cesarean section instruments. The
Nursing for Women’s Health
NICU team was preparing the infant warmer, setting up equipment and medications for the likely resuscitation of a 30-week infant. The circulating nurse had the patient ready. The bovie pad was in place, the foley catheter was draining and Christina’s abdomen was splashed with the prep solution. Both IV lines were open wide, trying to replace the volume that was being lost to the concealed bleeding in the uterus. With one of my hands I assisted the anesthesiologist with cricoid pressure, my other hand holding Christina’s cold damp hand. I suddenly felt time stand still as Christina looked at me with escalating fear. She understood that something was terribly wrong. Her blood pressure was dropping. I kept eye contact with her and continued to try to reassure her until the anesthesia induction was complete. I will never forget how her dark AfricanAmerican skin faded to gray, and how helpless she looked. The anesthesiologist hollered out “cut!!!” and the surgeon made the incision. Within seconds, he delivered a tiny, limp infant girl, covered in dark blood. As the NICU team took over the resuscitation of the baby, the anesthesiologist struggled to keep Christina’s blood pressure up, and called out for another two units of packed cells. Christina’s uterus was filled with blood, confirming the diagnosis of placental abruption. I assisted the circulator in getting misoprostil and IV fluids and in calling the lab. The NICU worked feverishly, intubating the 4 lb infant, performing chest compressions and inserting an umbilical line. A sigh of relief was felt by all of us when the neonatologist announced she heard a heartbeat. The baby was soon stabilized enough to be transported to the NICU for further care. Christina’s blood pressure steadily improved as the uterine bleeding slowed down. The unit secretary reported to me that she had made contact with Christina’s husband and he would arrive shortly. A sense of calm relief settled over the whole room. While the NICU team transported the baby to their unit, the anesthesiologist paid diligent attention to Christina’s vital signs, IV fluids and oxygen saturation. The circulator prepared for the infusion of more blood, while the obstetrician, obstetric resident and scrub nurse worked to control the bleeding and complete the cesarean section. Christina was unaware of all that was happening, completely dependent on the team
Volume 14
Issue 1
caring for her and her baby. I felt a great sense of relief that the baby had responded to resuscitation and that Christina was improving. Maybe we made it in time! I met with Christina’s husband when he arrived and explained all that had happened. He looked terrified, but I told him that his wife was stabilizing and that the baby was in the NICU. I accompanied him to the NICU and he was able to see his baby daughter and speak to the neonatologist. I was amazed how pink the tiny little girl now looked compared to the pale, limp infant I had seen in the operating room. I stayed with him while he visited his newborn daughter and then accompanied him back to the labor and delivery suite to wait for Christina to come out of the operating room. Several other concerned and supportive family members arrived. There were hugs and tears shared between them as they tried to understand the situation. I cleared an empty postpartum room and the nursing assistant and I brought in extra chairs to give the family some space and privacy. Christina was transferred from the operating room directly to the intensive care unit. Her platelets were low and coagulation panel elevated. Her bleeding, although diminished, was still of concern and it was apparent that her condition might be further complicated by disseminated intravascular coagulation. I escorted Christina’s husband and her parents to the intensive care unit. The obstetrician spoke with the family to explain all that had occurred and the need for close observation. We made accommodations for the family members who planned to stay overnight in the hospital near the intensive care unit. Christina finally woke up to see her husband at her side and was given the good news
that the baby was stable and seemed to be quite a fighter. Christina was cared for by compassionate intensive care unit nurses and physicians who collaborated with the obstetrical team regarding her postpartum care. I visited her several times in the intensive care unit and she returned to the postpartum unit 2 days later. She and her baby were doing well. She thanked me for “taking such awesome care of me, and saving my baby’s life.” My response was that it was our whole team that participated in her care and that we were all grateful for the outcome. She agreed with me and planned to thank them all later, but then added, “but yours are the eyes I will remember that made me believe I was safe, just before I went to sleep.” Driving home that evening, I reflected on all that had happened with Christina. So many things could have gone wrong, yet everything went smoothly. I was privileged to be working with a wonderful team of professionals, all performing at their best, which brought about the “higher level of care” we consistently strive to provide. I marveled at the idea that when I was feeling the least useful and effective in those moments just before Christina went under anesthesia, the silent eye contact we made was the last thing she remembered, and that it provided Christina some relief from her fear. My initial cynicism about ”just another false labor patient” was replaced with a renewed respect for the role nurses play as members of the health care team, providing not only clinical care, but also comfort and compassion, the lasting effect of which is unknown at the time. NWH http://nwhTalk.awhonn.org
Want to write for Nursing for Women’s Health?
N
URSING FOR WOMEN’S HEALTH is always seeking manuscripts on a wide range of topics related to women’s health across the lifespan, neonates and professional nursing issues.
Articles most likely to be selected for publication are evidence-based, timely, informative, engaging and practical. Remember, our ultimate goal is to publish articles that will help nurses provide optimum care to women and to newborns. To view our author guidelines go to http://www.editorialmanager.com/nwh and click on “Instructions for Authors.”
For questions, email [email protected].
February | March 2010
Nursing for Women’s Health
87
A Challenging Birth Experience
Laura Hubley, RNC, BSN, CN III
m
Maybe I was being cynical, or just a little wary, but when I received the message that there was an ambulance on the way with a woman 30 weeks pregnant and in labor, I was sure it was another false alarm. We had a busy Saturday on the labor and delivery unit, and things had just started to settle down as my 12-hour shift was coming to an end. I had been in charge that day, and I assigned the incoming patient to one of the other nurses whose patient had delivered about an hour before. I felt confident that she could continue to care for her new postpartum mother while evaluating the “ambulance patient” for her potential, but improbable, premature labor. After having sent several other mothers home with no cervical change that day, I expected this to be no different. Christina arrived on a stretcher and the ambulance crew helped us transfer her to a bed in
88
© 2010, AWHONN
the triage room. Her face was contorted in pain. She gasped and grunted short answers to our questions. While placing her on the fetal monitor, her nurse palpated the uterus and found a tight preterm abdomen, without the gradual release of a normal labor contraction. I made eye contact with the nurse and this provided no reassurance that this mother and her baby were not in imminent danger. There was no visible evidence of bleeding, but a diagnosis of placental abruption seemed likely. This was not a false alarm. Things happened so quickly. While the assigned nurse desperately searched for a fetal heart beat with the ultrasound transducer, I left the bedside to organize the staff for an emergency cesarean section. I directed the unit
(continued on p. 86)
http://nwh.awhonn.org
Laura Hubley, RNC, BSN CN III, is a nurse at Southern New Hampshire Medical Center in Nashua, NH. Address correspondence to: LauraAnnHubley@msn. com. DOI: 10.1111/j.1751-486X.2010.01513.x
86
coordinator to page the physician, resident and anesthesiologist, and to contact admitting, the lab and the neonatal intensive care unit (NICU). I reassigned the postpartum patient to a different nurse and directed another nurse to get the intravenous tray and fluids. The on-call physician arrived almost immediately. The fetal heart tracing showed a rate of 90 to 100 with minimal variability and a contraction pattern that suggested tetany. The doctor explained to Christina that most likely her placenta was beginning to separate from the wall of the uterus and she needed an immediate cesarean section to maximize the baby’s chance for survival. She started to cry while still coping with her physical pain. The obstetrician explained to her that she would need general anesthesia so that he could deliver the baby as quickly as possible. Her tear-filled eyes caught mine and I knew she was scared. Her nurse and I tried to reassure her by speaking calmly and explaining everything we were doing, even though it was all happening so rapidly. Christina’s husband was at work and she hadn’t been able to contact him before the ambulance picked her up. I assured her that our unit coordinator would do everything she could to try to get in touch with him. I told her who I was and offered to stay with her until he arrived. She was quickly prepped for the operating room. Routine procedures seemed to be accomplished within seconds. I started a second IV line in the operating room as the anesthesiologist prepared to intubate. The “time out” was called swiftly, accurately and loudly for all to hear. We heard the fetal heart tones seconds before the drapes went on. A slowing fetal heart rate intensified the atmosphere of urgency. I held Christina’s hand, feeling helpless at that point, but marveling at the calm, focused attention of the team moving swiftly about the room preparing for the delivery. The scrub nurse had the table neatly prepared with the stat cesarean section instruments. The
Nursing for Women’s Health
NICU team was preparing the infant warmer, setting up equipment and medications for the likely resuscitation of a 30-week infant. The circulating nurse had the patient ready. The bovie pad was in place, the foley catheter was draining and Christina’s abdomen was splashed with the prep solution. Both IV lines were open wide, trying to replace the volume that was being lost to the concealed bleeding in the uterus. With one of my hands I assisted the anesthesiologist with cricoid pressure, my other hand holding Christina’s cold damp hand. I suddenly felt time stand still as Christina looked at me with escalating fear. She understood that something was terribly wrong. Her blood pressure was dropping. I kept eye contact with her and continued to try to reassure her until the anesthesia induction was complete. I will never forget how her dark AfricanAmerican skin faded to gray, and how helpless she looked. The anesthesiologist hollered out “cut!!!” and the surgeon made the incision. Within seconds, he delivered a tiny, limp infant girl, covered in dark blood. As the NICU team took over the resuscitation of the baby, the anesthesiologist struggled to keep Christina’s blood pressure up, and called out for another two units of packed cells. Christina’s uterus was filled with blood, confirming the diagnosis of placental abruption. I assisted the circulator in getting misoprostil and IV fluids and in calling the lab. The NICU worked feverishly, intubating the 4 lb infant, performing chest compressions and inserting an umbilical line. A sigh of relief was felt by all of us when the neonatologist announced she heard a heartbeat. The baby was soon stabilized enough to be transported to the NICU for further care. Christina’s blood pressure steadily improved as the uterine bleeding slowed down. The unit secretary reported to me that she had made contact with Christina’s husband and he would arrive shortly. A sense of calm relief settled over the whole room. While the NICU team transported the baby to their unit, the anesthesiologist paid diligent attention to Christina’s vital signs, IV fluids and oxygen saturation. The circulator prepared for the infusion of more blood, while the obstetrician, obstetric resident and scrub nurse worked to control the bleeding and complete the cesarean section. Christina was unaware of all that was happening, completely dependent on the team
Volume 14
Issue 1
caring for her and her baby. I felt a great sense of relief that the baby had responded to resuscitation and that Christina was improving. Maybe we made it in time! I met with Christina’s husband when he arrived and explained all that had happened. He looked terrified, but I told him that his wife was stabilizing and that the baby was in the NICU. I accompanied him to the NICU and he was able to see his baby daughter and speak to the neonatologist. I was amazed how pink the tiny little girl now looked compared to the pale, limp infant I had seen in the operating room. I stayed with him while he visited his newborn daughter and then accompanied him back to the labor and delivery suite to wait for Christina to come out of the operating room. Several other concerned and supportive family members arrived. There were hugs and tears shared between them as they tried to understand the situation. I cleared an empty postpartum room and the nursing assistant and I brought in extra chairs to give the family some space and privacy. Christina was transferred from the operating room directly to the intensive care unit. Her platelets were low and coagulation panel elevated. Her bleeding, although diminished, was still of concern and it was apparent that her condition might be further complicated by disseminated intravascular coagulation. I escorted Christina’s husband and her parents to the intensive care unit. The obstetrician spoke with the family to explain all that had occurred and the need for close observation. We made accommodations for the family members who planned to stay overnight in the hospital near the intensive care unit. Christina finally woke up to see her husband at her side and was given the good news
that the baby was stable and seemed to be quite a fighter. Christina was cared for by compassionate intensive care unit nurses and physicians who collaborated with the obstetrical team regarding her postpartum care. I visited her several times in the intensive care unit and she returned to the postpartum unit 2 days later. She and her baby were doing well. She thanked me for “taking such awesome care of me, and saving my baby’s life.” My response was that it was our whole team that participated in her care and that we were all grateful for the outcome. She agreed with me and planned to thank them all later, but then added, “but yours are the eyes I will remember that made me believe I was safe, just before I went to sleep.” Driving home that evening, I reflected on all that had happened with Christina. So many things could have gone wrong, yet everything went smoothly. I was privileged to be working with a wonderful team of professionals, all performing at their best, which brought about the “higher level of care” we consistently strive to provide. I marveled at the idea that when I was feeling the least useful and effective in those moments just before Christina went under anesthesia, the silent eye contact we made was the last thing she remembered, and that it provided Christina some relief from her fear. My initial cynicism about ”just another false labor patient” was replaced with a renewed respect for the role nurses play as members of the health care team, providing not only clinical care, but also comfort and compassion, the lasting effect of which is unknown at the time. NWH http://nwhTalk.awhonn.org
Want to write for Nursing for Women’s Health?
N
URSING FOR WOMEN’S HEALTH is always seeking manuscripts on a wide range of topics related to women’s health across the lifespan, neonates and professional nursing issues.
Articles most likely to be selected for publication are evidence-based, timely, informative, engaging and practical. Remember, our ultimate goal is to publish articles that will help nurses provide optimum care to women and to newborns. To view our author guidelines go to http://www.editorialmanager.com/nwh and click on “Instructions for Authors.”
For questions, email [email protected].
February | March 2010
Nursing for Women’s Health
87
A Challenging Birth Experience
Laura Hubley, RNC, BSN, CN III
m
Maybe I was being cynical, or just a little wary, but when I received the message that there was an ambulance on the way with a woman 30 weeks pregnant and in labor, I was sure it was another false alarm. We had a busy Saturday on the labor and delivery unit, and things had just started to settle down as my 12-hour shift was coming to an end. I had been in charge that day, and I assigned the incoming patient to one of the other nurses whose patient had delivered about an hour before. I felt confident that she could continue to care for her new postpartum mother while evaluating the “ambulance patient” for her potential, but improbable, premature labor. After having sent several other mothers home with no cervical change that day, I expected this to be no different. Christina arrived on a stretcher and the ambulance crew helped us transfer her to a bed in
88
© 2010, AWHONN
the triage room. Her face was contorted in pain. She gasped and grunted short answers to our questions. While placing her on the fetal monitor, her nurse palpated the uterus and found a tight preterm abdomen, without the gradual release of a normal labor contraction. I made eye contact with the nurse and this provided no reassurance that this mother and her baby were not in imminent danger. There was no visible evidence of bleeding, but a diagnosis of placental abruption seemed likely. This was not a false alarm. Things happened so quickly. While the assigned nurse desperately searched for a fetal heart beat with the ultrasound transducer, I left the bedside to organize the staff for an emergency cesarean section. I directed the unit
(continued on p. 86)
http://nwh.awhonn.org