Last evening was a "good" evening shift in L&D. I was (surprise!) assigned to an orientee from our antepartum unit, who needed orientation on L&D. She mainly needed to see and learn about high risk OB, so that's what we were supposed to be doing. No problem. I like doing high risk OB. It keeps me on my toes with my assessment and critical thinking skills.
However, the unit wasn't busy last evening. Good for me, but not so good for my orientee.
Anyhow, we started off with a term gestation primip, age 26, who had a c/o of vaginal bleeding. Her BP was also fairly elevated, which meant several differential dx: Preeclampsia, placental abruption, early/active labor. Here is my thinking process, which I will share with you:
Risks for preeclampsia: elevated BP readings, primipara.
Risks for placental abruption: vaginal bleeding (moderate amount, dark red, no clots), elevated BP readings, possible preeclampsia, no uterine tenderness.
Early/active labor: vaginal bleeding, some contractions, some c/o of vaginal pressure.
More clinical info presented:
SVE 4cm/100/+1
Preeclampsia labs all WNL
Serial BP readings: when sitting up BP was 140's over 90's. When in left lateral BP was 130's over 80's.
Denies all s/s of preeclampsia: no HA, no epigastric pain, no visual changes. Minimal pedal edema. Reflexes all +2.
FHR on EFM was reactive with good accels, no decels. Toco was readjusted several times. Contractions started to pick up and trace at every 2-3 minutes. She only c/o of pressure feelings, no pain.
What do you think happened next?
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12 comments:
I'm guessing a c-section? Even though, other than the bleeding there was no indication for one. Did they find the cause for the bleeding?
My hope for her was that labor just kept moving right along and she had her baby!
a labor augmentation hopefully followed by a NSVD
My guess would be she's in labor. Still possible that she has an abruption but as long as strip is reactive, I would proceed with labor snd hopefully vaginal delivery :)
I would hope to allow her to have a sleep, and see what eventuates (hopefully an SVD). But know intervention, probably augmentation, epidural, nonreassuring trace and emergency cs.
Had to be interesting...otherwise no post, huh? Blood pressure could have been pain related. How did her uterus palpate? Were contractions strong? Did the pattern look like an abruption? Baby didn't appear to be responding to one though. Did mom come in for bleeding or pain? Early labor that needs to go home? Did she have protein in her urine? How long had she been contracting? Tired?
as a L&D nurse, i can imagine that an ultrasound was done to examine the placental borders, and to confirm a vertex position. A few more blood pressures were probably requested by the resident. and at 4 and 100%, i would hope she was admitted. I can imagine they gave her an hour between checks, made a decision on her natural progress and began PPP if she went no further than 4. But with the bleeding more-than-likely being a sign of cervical dilation-- maybe she just pushed the kid out in triage and gave your orientee a real welcome!
Ooh... a mystery! I like! But I have no idea what happened next. I'll venture a guess and say that she was went on to have a normal, vaginal delivery. I don't think this was a high risk birth since you stated your orientee needed to participate in high risk but didn't get any that night.
Considering you work at a tertiary care center and I don't know if they are as Mag lovers as the ones here, so here is what I think happened... in no particular order
1. labs including urine dip for protein
2. admit
3. magnesium
4. pit
5. epidural
6. delivery
One word: Precip.
So what happened? I wanna know because this sounds exactly like my situation a year and a half ago, except my baby had decels.... otherwise EXACTLY- even age! (Had a sono, no new info, ended up with Emergency C/S -due to fetal distress- and they discovered a 40% placental abruption.)
Going for VBAC in March.... wish me luck:)
I am guessing they checked to see if she had a marginal previa. Then, I hope she had a spontaneous vaginal delivery. Any chance of that?
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