You are working in a high risk L&D unit and just received a call from Dr Green s

Question

You are working in a high risk L&D unit and just received a call from Dr Green saying that he is sending in a 38 year old approximate 32wk G2P1 in for elevated blood pressures in the office and is needing an NST, continuous monitoring of BP and further labs. The patient was a drop-in to the clinic without previous prenatal care. She is unsure of her LMP and states that her two year old son “came early” at 36 weeks which was a vaginal delivery without any anesthesia, “because he came so fast”. She is not reporting any contractions or pain at this time. During her office visit she presents at 2/70/-3. She has no support person with her.

It has been 45 minutes and Mary’s condition has not changed, her last BP 190/95, and the doctor still has not returned your calls even though you have called him three times.

What do you do now?

Explanation / Answer

Scenario:

Assessments noted:

Interventions to be carried out:

1. Continuous monitoring of the patient’s condition:

At first, the patient should be connected to a cardiac monitor and her temperature, pulse rate, respiration, blood pressure, oxygen saturation and ECG pattern should be closely monitored. These are the basic assessments that reveal the general hemodynamic condition of the patient. Often, the monitor is set to check her blood pressure once in every 10 minutes.

2. Continuous monitoring of the foetal condition:

It is also crucial to constantly monitor the condition of the foetus. This can be done be checking fetal heart rate through fetoscope. Also, foetal heart rate monitoring should be done using a Non-Stress Test (NST) to continuously monitor the health of the foetus. Here, the foetus’s heart rate is monitored to check how it responds to movement of the foetus. Usually, a NST is done when a foetus is at increased risk of death.

3. Sending out the lab investigations immediately:

As the mother’s prenatal health record is not available, routine blood investigations like complete blood count, urea, creatinine, electrolytes, serology testing (testing for HbSAg, HCV, and HIV) should be done. Moreover, checking group B streptococcal status is also important. Therefore, after immediately securing an IV line, blood samples should be drawn and sent to the lab. The lab personnel should be informed to notify the results at the earliest.

4. Assessing the risk for mother and the baby:

The health professional should note that the mother has a history of preterm vaginal delivery of a live baby. Therefore, there is also an increased chance of preterm delivery now.

5. Implications of consent:

The heath professional or a registered nurse/midwife can initiate appropriate interventions by herself as the physician is not available for emergency and at the same time there are no patient’s relatives or representatives to get appropriate consent. Here the consent is implied.

6. Managing hypertension:

Elevated hypertension also known as per-eclampsia increases the risk of maternal death and is a medical emergency during labour and delivery. First line of anti-hypertensive drugs such as Methyldopa, sublingual Nifedipine or oral Hydralazine can be administered. They are all safe throughout pregnancy. For example, a nurse may give sublingual Nifedipine 5 mg initially then monitor her blood pressure and then administer another 5 mg if required.

7. Assessing Bishop score:

Vaginal examinations indicate 2 cm cervical dilation/ 70% cervical effacement/ -3 station head.

Bishop score is a score of measuring the status of pregnancy. It consists of

The score can range from 0 to 15. A score less than 3 indicates the need for induced labour and the score of 8 or more means the possibility of spontaneous vaginal delivery. This score provides information regarding the likelihood of delivery and the type of interventions required i.e. the possibility of normal vaginal delivery or whether induction with some medications to promote contractions are required.

As some of the details are not available (the information regarding cervical consistency and foetal position) it is difficult to determine the exact Bihsop score with the available information). Therefore, the health worker must assess the patient thoroughly to include all the data and measure the Bishop score.

The heath worker after calculating the bishop score can communicate the physician and wait for some time till the physician arrives. Meanwhile, she must constantly monitor her vital signs, conduct frequent vaginal examinations and do foetal heart monitoring.

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