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whitewriterOn November 11th, a baby died in utero. I was right! I was on that day. And I know I was because it took ages to get help in my room; and I heard about it second hand from Andrew. Then I promptly wrote about when I got home
- and comparing it to the facts explicitly discussed in the RCA is an eye opener.
At the time, according to the RCA the woman had all along, been determined to be in early labour.
At the time (that the fetal heart could not be found), the woman did not know the baby had died.
However on previous hourly fetal heart checks (hourly because she was in early labour. If your in active or established labour - then it would be checked at a minimum of 15 minutely the HR was noted to be fine.
One hour the HR was missed because the midwife in charge of that case was pulled away elsewhere (as it was determined the woman was in early labour and didn't need 1:1 care as they do in established labour).
On her return, she had chosen to put in an IDC prior to attending to the fetal heart as the woman had not voided since quite some time. (So likely the baby had died, whilst this was happening).
Imagine not realising something was wrong and just going about what your doing - and then realising, that the worst thing that could possibly happen, had happened and it was now too late to go back...
The RCA found:
That the unit had a high volume of high acuity women (totally agree) and no staffing shortages that day (didn't quite feel like it when i was with a VBAC woman pushing for over an hour and no one was coming to review my room... Hello uterine rupture? does anyone care?).
Figuring out when someone is or isn't in established labour is tricky.
What is established labor?
They say it's when a multip reaches 4cm dilation
and when a prinip reaches 6cm.
and that they have regular, painful contractions, every 2-5 mins (so 2-3 in 10 minutes) lasting 50 seconds or longer.
This woman hadn't any VEs due to Hx SROM so they determined she was 3cm via a spec.
So we're encouraged to not do VEs on SROMs but in this case, it seemed like it might have been a good idea.
The kicker is that endone 10mg was given twice to this lady, two hours apart.
The RCA team determined that perhaps the endone masked the signs of transition from early to established labour.
I was taught recently you can only give endone and morphine once.
At the beginning of it all, and once it wears off - then you'd move onto the next options (gas, or epidural for pharmacological options) and non pharmacological were sorta always there all along (heat pack, warm shower or bath, etc. ) if needed.
the baby would have been really sick: it had chorio on autopsy.
The early morning's CTG showed nil signs of distress.
It's a horrible story.
Honestly it could just as well have been me whom had that lady and made that same error to give more endone and mask "early labour".
- and comparing it to the facts explicitly discussed in the RCA is an eye opener.
At the time, according to the RCA the woman had all along, been determined to be in early labour.
At the time (that the fetal heart could not be found), the woman did not know the baby had died.
However on previous hourly fetal heart checks (hourly because she was in early labour. If your in active or established labour - then it would be checked at a minimum of 15 minutely the HR was noted to be fine.
One hour the HR was missed because the midwife in charge of that case was pulled away elsewhere (as it was determined the woman was in early labour and didn't need 1:1 care as they do in established labour).
On her return, she had chosen to put in an IDC prior to attending to the fetal heart as the woman had not voided since quite some time. (So likely the baby had died, whilst this was happening).
Imagine not realising something was wrong and just going about what your doing - and then realising, that the worst thing that could possibly happen, had happened and it was now too late to go back...
The RCA found:
That the unit had a high volume of high acuity women (totally agree) and no staffing shortages that day (didn't quite feel like it when i was with a VBAC woman pushing for over an hour and no one was coming to review my room... Hello uterine rupture? does anyone care?).
Figuring out when someone is or isn't in established labour is tricky.
What is established labor?
They say it's when a multip reaches 4cm dilation
and when a prinip reaches 6cm.
and that they have regular, painful contractions, every 2-5 mins (so 2-3 in 10 minutes) lasting 50 seconds or longer.
This woman hadn't any VEs due to Hx SROM so they determined she was 3cm via a spec.
So we're encouraged to not do VEs on SROMs but in this case, it seemed like it might have been a good idea.
The kicker is that endone 10mg was given twice to this lady, two hours apart.
The RCA team determined that perhaps the endone masked the signs of transition from early to established labour.
I was taught recently you can only give endone and morphine once.
At the beginning of it all, and once it wears off - then you'd move onto the next options (gas, or epidural for pharmacological options) and non pharmacological were sorta always there all along (heat pack, warm shower or bath, etc. ) if needed.
the baby would have been really sick: it had chorio on autopsy.
The early morning's CTG showed nil signs of distress.
It's a horrible story.
Honestly it could just as well have been me whom had that lady and made that same error to give more endone and mask "early labour".
