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bad babies and BAD dayFrom: Babycatchers@aol.comMon Nov 28 18:50:34 2005
Dear list: I need to vent a minute and I have a legitimate question at the end. We have had 17 babies in 12 days, so my brain is not working on all cylinders. ( We usually do 30 births a month) Last Monday we shipped out 4 babies and 2 moms. One for cardiomegaly, one for RDS (term), one that wouldn't keep his blood sugar over 40-even with feedings q 2 hours and an IV (mom was not a diabetic-no family history) and one for a spontaneous pneumothorax.So I am a little paranoid. Today I had a 17 yo show up in the office. She had been to the ER on Sat and Sun for urinary retention and pain. The ER doc put her on Bactrum and pyridium on Sat, then when she came back on Sunday-having not voided in over 24 hours, he changed the antibiotic to amp and put in a foley with a leg bag and did a BHCG. He told her she was 16 weeks pregnant (no US done) and told her to show up at our office this morning. On Monday mornings it is just me (CNM) in the office. The OB does afternoon hours on Monday. She shows up and we work her in. She presented with the leg bag full. She denied that she could be pregnant at all. (I forgot to mention she was 5'4" and weighed over 300 pounds.) Something looked weird about her and the physical exam made me very nervous. Palpation of abd felt like a big baby to me. Speculum for pap and GC/CH revealed no cervix and a head full of hair. Her pelvis was heart shaped and narrow. I had the OB come in and do an US. He thought she was 37 weeks with a 2700 gms baby. So she is sent to OB for prenatal workup and delivery. We have no idea when her water broke or any idea what we were really dealing with. She labored for several hours and pretended to push. She was 17 and in denial and still did not believe she was actually pregnant-so why push. I ordered 2 gms Amp and she got 2 doses. She became febrile at 101 degrees, so the OB decided to section her. The 2900 gram male was born with pus pouring out of his nose and mouth. The ped was there and is doing the workup for the baby. Mom's uterus shredded when we were going in and I lost count of the number of laps we had to use to get the uterus clean. It has been a long time since I have seen one tear this badly. (I first assist at all surgeries.) It took us a lot of time and patience to put the puzzle back together again after cleaning out the uterus and doing antibiotic fluid irrigation of the belly. She is going to be on amp/gent/clindamycin IV. Now my question: The OB is going out of town and the covering OB is about 30 minutes away and does not like our practice. I am trying to make sure that I cover all the bases, because I am on my own until I can beg this OB to visit. After tomorrow it is just me in this town. (One of the back up doc's patients coded in our OB department and the ER doc and I ran the code. She did not visit the patient until 24 hours after the problem). What else should I do besides a culture of the placenta (done), send it to pathology (done), cover her with the antibiotics that will stop a truck (done). I didn't get blood cultures before I gave the first dose of Amp, I didn't realize how bad it really was. Her WBC on admission was 16, but the doc figured it was from the UTI. She is bleeding a little more than I am comfortable with, but not time for methergine yet. Fundus firm. BP beginning to climb. 120s/80s on admit- now 160s/80s. 1-2 + bilat pedal edema. 2+ reflexes. Temp still 101. I am telling everyone I can find that this is OUT OF MY SCOPE-but the administration and the OB think I can handle it. I will climb the food chain when it gets bad. But I need to have my ducks in a row when I do it. Other than a CBC in am, lytes, liver function tests, uric acid and chem panel - what else should I do? What should I be looking for so that I can catch this before she crashes? Any help would be appreciated. Vicki, CNM Vicki Smith, CNM Midwives-changing the world one baby at a time.
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