An Obstetrics Dance: Preparing for the Arrival of a Preemie

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An Obstetrics Dance: Preparing for the Arrival of a Preemie

The medical team rehearses all likely outcomes as baby Hannah enters the world five weeks ahead of time

By Karen Buley, RN, BSN
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“Rachel’s scheduled for a cesarean at noon,” Marie, our charge nurse, said. My stomach knotted. 

Rachel had been admitted at 30 5/7 weeks gestation with bright red vaginal bleeding. Her placenta covered her cervix — a complete placenta previa. Because she ran the risk of maternal hemorrhage with resulting oxygen deprivation to her unborn baby and lived in a small town 27 miles away, our OB unit had become Rachel’s temporary home.

She was two days shy of 36 weeks.

Two days from a scheduled amniocentesis and — provided her baby’s lungs were mature — a cesarean delivery.  But due to recent spotting, and contractions which had quieted with medication, the decision was made to deliver Rachel’s baby this day before an emergent situation arose. Her placenta covered her cervix and was attached to the front wall of her uterus, where the surgical incision would be made. The possibility of hemorrhage during surgery, resulting in the need for a hysterectomy, was a major concern.

I looked through Rachel’s chart. Every three days, lab had drawn blood for cross-matching, so packed red blood cells would be ready if needed. “We have two units available,” I said to Dr. P., Rachel’s obstetrician, seated at the labor desk.
“I want four,” she said.
I called lab and ordered two more, as our secretary did the necessary paperwork.
“Anesthesia knows,” Marie said, “and will be over early to start the second IV if you want.”
“Good,” I said.

The Big Day

With Rachel’s increased risk of hemorrhage, the plan was for two IVs, larger than the 18-gauge we typically used, to be in place for surgery. The night nurse had inserted a saline lock because of the onset of spotting and contractions. Today, we’d need the second IV.
I went into Rachel’s room. “I hear today’s the day,” I said, before beginning my morning assessment. 
“It is,” she said, with a hesitant smile.

For five weeks, we nurses had bonded with and monitored Rachel and her baby. Early on, we’d administered intramuscular steroids to facilitate baby Hannah’s lung development. Today, we’d welcome her with Rachel and her husband James.

As I positioned the fetal monitor, I reiterated our pre-op teaching, which Rachel had heard before. I learned that another nurse had taken Rachel and James to see the operating room where Hannah would be born.

Dr. P. came in, again reviewing the cesarean and its resulting risks. “You’ll be awake,” she said, affirming there would be communication with Rachel and James during surgery.

Lab drew blood for a current blood count. I attached an IV to Rachel’s saline lock and administered medications to hasten stomach emptying and decrease stomach acid.  Throughout the morning, I ensured her consents were in order, placed compression stockings, administered a prophylactic IV antibiotic, administered oral medication to neutralize stomach acid, obtained vital signs, clipped hair at the surgical site, and completed the pre-op checklist.

“I’m glad this wasn’t an emergency,” Rachel said.
“Me, too,” I replied.

Backstage

Before gathering IV supplies for Dr. C., the anesthesiologist, I asked, “Do you want me to get blood tubing and normal saline?”
“That’s a good idea,” he said. “If we have it, hopefully we won’t need it.”
“That’s my plan,” I said.

I assembled the IV in Rachel’s room, showing her the filtered, Y-tubing and compatible solution we would have in place should blood administration become necessary.

“We hope not to need it,” I said. 

When Dr. C. came into the room, he recapped our conversation before inserting a 16-gauge. While he held pressure, I attached the tubing and IV solution, then applied a sterile dressing and tape.

Behind-the-scenes activities unfolded. I called Rachel’s pediatrician, who would be present at the birth, and also talked with the neonatal intensive care nurse who would be in attendance. Our surgical tech Whitney assembled the necessary equipment, and placed the hysterectomy cart outside the OR door. Just in case. 

The Curtain Goes Up

Marie and another OB nurse Lynn set up the “rapid infuser” in OR: a special pump used to warm and quickly deliver blood and IV fluids. After Marie obtained a cooler, cold packs, and two units of packed red blood cells from the lab, she and Lynn performed the necessary two-person check at Rachel’s bedside. They checked Rachel’s name and medical record number on her hospital band, checked her name and number on her blood band, and checked the identifying features — type — Rh — expiration date — number — on the labeled blood units, matching all with the lab slips that confirmed that this patient, and these two units, were compatible. They recorded their checks on blood transfusion forms, pre-preparation that — if blood administration became necessary — would require only a quick reconfirmation of name and numbers, thus saving valuable time.

With each cautionary measure taken, we explained our purpose to Rachel and shared our hope that by having the blood and special equipment ready, we’d preclude their need.

I obtained scrubs for James, and advised the grandparents where they could wait to see Hannah, James and staff when they made their way from the OR to the nursery.

Whitney and I performed a count of sponges, sharps and instruments before I went to assist in Rachel’s transfer to OR 4. Lynn, who was helping her into a wheelchair, said, “I’m going to miss coming in here to see you,” then added, “you’re going to make me cry,” as she and Rachel shared a hug.

When the initial OR procedures had been completed and Rachel was prepped and draped, James was escorted into the room and seated on a stool near Rachel’s head.

Showtime

Extra personnel were assembled — two anesthesiologists, Rachel’s obstetrician, a perinatologist, two scrub techs, a pediatrician, two neonatal intensive care nurses, a well-baby nurse, and Marie, Lynn and I — for this high-risk birth. As always, equipment was ready for a neonatal resuscitation. Another OB nurse was on standby, ready to hurry to the lab one floor below to pick up two additional units of blood if needed.

When Dr. P. said, “scalpel,” the room was silent, save for the sounds of suction and the steady beep of the cardiac monitor. We all held our breath, and let it out slowly as Hannah was born.

She breathed spontaneously. After being suctioned, dried, assessed; and having ID bands, a warm hat and blankets applied, she was carried over to say hello to her parents before James accompanied her and a nurse to the well-baby nursery. 

By ones and twos, staff exited the room, grateful that the hemorrhage and neonatal resuscitation we’d prepared for didn’t happen. Only four of us and Rachel were in the room at surgery’s end.  The choreographed dance that had taken place that morning had the sweetest result — for which we all had hoped.   

Karen Buley, RN, BSN is an obstetrics nurse who recently edited a collection of stories by nurses, Nurses on the Run: Why They Come, Why They Stay. 

This article is from workingnurse.com.

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