Ms. C went to a clinic appointment for a routine US and was found to have a shortened cervix and contracting. The team admitted her to the hospital. Her cervix was now 3-4 cm. After monitoring her, she was transferred to the ICU for close monitoring given the cervical change and possibility for delivery. Complicating her course has a past medical history of congestive heart failure, non-ischemic cardiomyopathy, nonrheumatic mitral valve regurgitation, nonrheumatic tricuspid (valve) insufficiency, obesity, and postpartum cardiomyopathy. Her last known ejection fraction was <20%. Needless to say, delivery was a huge risk to this mom's life.
The team planned to try and delay preterm labor with medications and fluid. The nursing staff remained at the bedside to monitor the baby and manage her preterm labor. With time, we were able to stop her labor progression. The plan, for now, was to let the baby grow a little and continue to monitor Ms. C for any signs of preterm labor as she appeared clinically stable despite her cardiac complications. She was transferred to the next unit in the afternoon. Here, both mom and baby were monitored. The next day her echo showed an EF of 10%. We continued to monitor her closely and began to work on a plan for delivery.
Two days later, several departments met and decided it would be best for mom and baby if she delivered at 28 weeks. We transferred her back to the ICU that evening to prepare for delivery there.
In the morning, the Doctor and the NM of the ICU met to discuss the plan of care for Ms. C to determine timing, safety, and care in the delivery of the infant. It was decided with input from one of our neonatologists that postponing delivery another week gave minimal benefit to the infant, and increased risk of maternal morbidly if the pregnancy was to continue. The decision was made to deliver the infant the next day. Aware of the patient and necessary supplies at the bedside in ICU. After this, true interdisciplinary collaboration began.
NM in the ICU reached out to the charge nurse, who reached out to NM Antepartum, covering for Labor and Delivery the ART OR team, and Doctor reached out to Neonatology, OB, Anesthesia, and scheduled a meeting of the minds for early that afternoon. This collaboration included bedside nurses, nurse leaders, physicians, and representatives from the OR.
In this meeting, the question of where we would go if Ms. C needed a cesarean section was brought up by nursing. The ART OR stated that they didn't have the capability to do this if needed in an emergency. We discussed doing this at the bedside, but this was not ideal for the patient and increases infection risk dramatically. The doctor suggested that we bring Cardiology in. This was not thought of before but was a reasonable solution. Once the plan was made the teams began all the work together to plan for a safe delivery for this patient. Ms. C would come to Labor and Delivery in the morning to begin her induction of labor.
After this meeting, Kaylen Dodson, the nurse caring for Ms. C came to L and D to look at the room that she would be in and see what supplies and equipment she would need to care for her there. We brought a computer on wheels, pumps, channels, spoke with the pharmacy to prepare the needed drips, reviewed the route of transport. All of these thoughts and planning were done with nursing. Having what was needed in place was critical to the success of her delivery and care. CVICU nursing input, led by Kaylen, was critical in the success of this.
After doing this, she called her babysitter to see if she could watch her child the next day so that she could pick up extra to be with Ms. C through her delivery. By this point, she had formed quite the relationship with Ms. C. Ms. C asked her if she would be there, and Kaylen did what she could to make this request happen. The CVICU team also called the Chaplin to visit with the patient the evening before her delivery. Kaylan demonstrated patience, compassion, and advocacy for this patient. It was wonderful to see.
On L and D, Danielle Klinski volunteered to take this patient. She also rearranged her schedule to do this. She began to organize what she would need. She has been a Labor and Delivery nurse for 2 years and continues to impress her team with her compassion and desire to continually grow and learn. The charge nurse made sure there were enough channels, pumps, and an extra computer in the room so that both nursing teams could chart. Danielle was by this patient's side all day. She was there for the delivery. She was so kind and did a great job explaining all the details of what was happening to the patient. Both Danielle and Kaylan represented what it means to be a nurse at MUSC.
There was one more final meeting at 5 pm that evening with OB Anesthesia, Maternal-Fetal Medicine team, Cardiology, and Nursing leaders for any final questions or concerns. The plan was made to bring the patient to L and D at 7 am. Nursing decided to have the night shift from the CVICU to give report to Kaylen and then bring the patient and stay with her and Danielle on L and D through delivery. We also discussed the placement of her epidural and the plan to start induction after.
At 7 am, Ms. C was transferred seamlessly to L and D with Kaylen, the night RN, and the pharmacist at her side. Dr. C presents on L and D through delivery. The patient labored throughout the day with both CV and L and D RNs providing care. Labor progress was minimal throughout the day and the patient remained stable. It was decided early evening to perform a Cesarean Section. The baby was born at 6:10 pm, with stabilization present and ready, with APGARS of 7 and 8. Night CVICU RN reported to L and D at 7 pm, received report and transferred patient back to SVICU when OB recovery complete. Ms. C stayed in CVICU and did quite well. She was transferred to the floor and discharged home soon after.
The multiple minds involved in this allowed for a successful delivery. It really was a wonderful example of interdisciplinary care with extraordinary care by both Kaylen and Danielle and all others who provided care for this family.