A Minor Detail: Heidi Creston

Handling the medical treatment of a minor can be tricky. Heidi Creston is back to discuss some of these special circumstances.

Welcome back, Heidi!

I work in L&D, and by far, dealing with family issues is more demanding of my time and energy than anything else. There is one issue that continually pops up and more and more I am finding it in the books I’ve been reading as well. I’m not an expert but I’d like to toss my two cents in for whatever it’s worth.

There are three primary condition that will emancipate a minor WITHOUT a court order:

1. Marriage
2. Joining the Armed Forces
3. Reaching the age of 18

Marriage or enlistment in military service by a minor brings about a new relationship of obligation and responsibility between the child and someone other than the parents. The severing of the child-parent relationship in this manner constitutes as an implied emancipation.

Substantiated reports of desertion, abandonment, non-support and other conduct of the parent may constitute reasonable circumstances for implied emancipation of a minor depending on the age and maturity level of the minor.

Pregnancy, in most states, does not constitute for implied emancipation. The pregnant minor is MEDICALLY emancipated, meaning they can make medical decisions for themselves and their baby only. The best option is to research the emancipation laws in the state that your are writing about because regulations vary from state to state.

Some states are pretty liberal with their emancipation procedures and a judge can sign off on it without a hearing if all parties involved are in agreement. So if you are planning some animosity within your story with those teenagers, take a quick peek at the laws first.

Marriage is another minor detail as well. Some states, like Wyoming, the legal age of marital consent is 19, not 18. So there is good reason said boy had to talk to girl’s dad first.

Jordyn here: I did a series as well on HIPAA issues that you might find interesting. Several aspects of this law are violated by authors frequently. Check these links for further information.

1. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-13.html
2. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-23.html
3. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-33.html

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.

Obstetrical Emergencies: Prolapsed Umbilical Cord

If you’re a writer and you are wondering about a grave situation to put a pregnant, delivering woman into– this might be your solution. A prolapsed cord.

Heidi Creston, OB RN extraordinaire returns to discuss this obstetrical emergency.

Welcome back, Heidi!

The umbilical cord connects the baby from its umbilicus (belly button) to the placenta (afterbirth) inside the uterus (womb). The cord contains blood vessels, which carry blood, oxygen and nutrients, to the baby and waste products away. After the baby is born, the cord is clamped and cut before delivery of the placenta.
A prolapsed cord is when the umbilical cord slips or falls through the open cervix (entrance of the womb) in front of the baby before the birth. When the cord prolapses, it reduces the amount of blood and oxygen supply to the baby. This causes an emergency situation, which requires immediate delivery of the infant.
A doctor, midwife, or labor nurse will need to insert a hand in your vagina to lift the baby’s head to stop it from squeezing the cord. Alternatively a catheter (tube) may be put into your bladder to fill it up with fluid. This will help to hold the baby’s head away from the cord and reduce pressure on it.
If the provider is able eliminate pressure on the cord through positioning, and the vaginal delivery is imminent, then they may proceed with the vaginal birth. Most providers will perform an emergency Cesarean section.
Patients will be placed in a knee chest position, in order to reduce compression on the cord. The labor nurse will hold the fetus’s presenting part in the vaginal canal, when the physician is ready, the nurse will apply pressure pushing the fetus back up into the uterus. The physician will then remove the infant via Cesarean section.
A prolapsed cord is a desperate situation for the infant requiring everyone to work very quickly.
           
Prolapsed cords are usually the result of multiple gestations (twins, triplets etc), malpresentation of the fetus (transverse or breech), polyhydramnos (to much fluid around the baby), artificial rupture of membranes (water breaking), or if membranes rupture before head is fully engaged.
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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.
Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 

Medical Question: Flu and Pregnancy

Bonnie asks:

My question has to do with one of my characters who gets a deadly form of influenza (swine and avian flu combined) early in her pregnancy. She winds up in the ICU. She survives but then discovers she’s pregnant. She worried about the baby.

What are the possible dangers to the baby?
Heidi says:
The flu is actually more dangerous to the pregnant woman herself than to the fetus. Most women and healthcare providers delay preventative and treatment of the flu because they fear possible effects on the baby. More women in their third trimester of pregnancy die of the flu, than anything else including accidents and domestic violence.
Untreated flu symptoms that can and usually do send pregnant woman to the ICU include such things as high fevers, dehydration, and viral infections. The effects on the fetus include an increase in still births, brain damage, premature birth, and spontaneous abortion. Woman early in pregnancy are at greatest risk for spontaneous abortion. This would be the case for your patient. Treatment of the flu (antiviral’s), is the best thing for this patient, the benefits greatly outweigh the risks.
I encourage all pregnant patients to get the flu shot and to call their health care provider immediately for flu like symptoms. Tamiflu and Relenza work best when given within the first 48 hours of flu symptoms. Always your best defense is a good offense, get your flu shot.
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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.
Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 

Nurse Assisted Deliveries: Heidi Creston

Babies come when they want to, not necessarily when we want them to. Every labor and delivery nurse and OB provider are well aware of this fact. Nurse assisted deliveries happen daily.

The primary reasons for nurse assisted deliveries are:

  1. Physicians are over extended.  They have more than one patient delivering at one time or are  covering OR and/or ER as well as OB.
  2. They are not on site due to office hours.
  3. Precipitous Deliveries (baby comes quickly).
Labor and delivery nurses are specially trained to monitor and keep close observation on a patient’s status in order to notify the OB provider in a timely manner. Most patients are kept on continual electronic fetal monitoring. The pattern on the fetal strip provides information concerning both fetal and maternal status to include how soon delivery may be.
Sterile vaginal exams or cervical examinations to monitor dilation is another skill that L&D nurses are trained to perform. Nurses also educate their patients to report any signs of increased pressure.
It is always preferable for the OB provider to be present for the delivery, due to the increased risk to the patient (possible birth complications such shoulder dystocia), but in the event the provider does not make it, labor nurses are trained to deliver.
The L&D staff will make every effort to contact the provider, they will stop any measures taken to induce labor (turn off pitocin, instruct patient how to breathe thru contractions), provide support, and set up for delivery.
If the delivery is imminent, the nurse will guide the patient in her delivery, guiding the head, checking for nuchal cord. A nuchal cord is when the  umbilical cord is around the neck.  In some cases the cord can be untangled by hand.  Tight cords need to be reduced, clamped and cut.
Nurses also must be careful of other body parts being entangled by the cord as well. Delivery of the body is usually rapid once the head and shoulders are out.
If there are no complications with the infant, nurses will usually leave the baby on the mother’s chest with an uncut cord for 3-5 minutes. Nurses do not attempt to deliver the placenta, but if the placenta delivers spontaneously they place it in a container for the provider.
After delivery, if the provider remains unavailable, the nurse will clean the perineum and assess for tears and bleeding. Given the situation (excessive bleeding) the nurse may restart the pitocin, give a dose of methergine or hemabate, provide continuous fundal massage, and or perform a vaginal sweep. Upon arrival of the provider, the nurse will give them a full report.
Although most deliveries are uneventful, there are many things that could go fatally wrong with the delivery itself or during the post partum period. These include but are not limited to: malpresentation (ie: breech, compound limbs), cord prolapse/cord accidents/nuchal cords/body cords, placental abruption, and post partum hemorrhage.

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

 
Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.

Perinatal Providers: Scopes of Practice

Heidi Creston returns today for her monthly blog post. Today, she covers a very important topic: scope of practice for different obstetrical providers. Scope of practice dictates what a medical provider can and cannot do so it is important to know a particular providers limitations. For instance, as a registered nurse, I cannot diagnose illness though most nurses are very good at this very thing and we may indicate to a family what we think is going on. However, only a physician, nurse practitioner, or physician’s assistant can diagnose.

Now, I’ll turn it over to Heidi.

It is especially challenging for the perinatal patient to understand the scopes of practice that different providers offer. As authors, we must remember that our audiences are impressionable, and may believe your fictional story as the Gospel truth. If your character is a perinatal provider it is imperative, that you keep them working within the means that their occupation allows.

The providers:  Obstetrician-Gynecologist, Perinatologist, Family practitioner, Certified Nurse Midwives, and Doula’s.

Obstetrician-Gynecologist (OB/GYN) is a medical doctor who provides both clinical and surgical care for their patients. The OBGYN serves not only the perinatal patient but all women’s medical issues from puberty to post hysterectomy.

Perinatologist is an obstetrician who specializes in the care management of high-risk pregnancies. Patients assigned to a perinatologist are referred out by their OBGYN or family practitioner due to the extensive or specialized care that is required maternally and or for the fetus. Patients with cardiac issues, diabetes, Eclampsia or HELLP, and multiple gestations are prime examples of patients referred to perinatologists. Fetuses with severe abnormalities such as gastrocentisis or Tetralogy of Fallot are also referred.

Family practitioner is a medical doctor who specializes in the health care of all family members. They are prepared to provide normal OB/GYN care, but usually refer pregnancies and other women’s health issues to an OB/GYN. All family practitioners are trained to perform Cesarean births in an emergency and also to assist other specialists in doing the procedure.

Certified Nurse Midwives are registered nurses who have earned their master’s degree in nursing, with a strong emphasis on clinical training in midwifery. Midwives work with obstetricians who are always available to assist if complications occur during pregnancy, labor, or delivery. CMW’S can assist with cesarean sections but can not perform them independently.

Doulas are not licensed or certified personnel. Doulas are support liaisons hired by the patient, to assist them through the pregnancy, and offer support during the labor process. There currently are no mandatory qualifications, regulations or requirements necessary in order for someone to become a doula.

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 

Medical Question: Drugging a Pregnant Woman

Sheila asks: In my WIP, I have the good guy (a doctor) trying to get the pregnant heroine away from a dangerous situation. She resists so I thought he might give her an injection to knock her out. Is any drug available to put a pregnant woman into a deep sleep that is not harmful to the fetus?
Jordyn says: First thing to know is that every drug has a pregnancy classification given by the FDA based on its potential harm to a growing baby. You can find an example of this at this web site: 

http://www.safefetus.com/fda_category.asp

Based on this, you can look up certain drugs and get a hint about their potential harm to the baby.
I looked up several drugs that could be injected to knock a woman out.
Benzodiazepines are all injectable… this would be Valium, Versed and Ativan. Given rapidly IV, they could knock the woman out but also depress her ability to breath. This could harm the baby. They are all category D on the scale which denotes that there is evidence of potential harm. However, how far along is the woman in her pregnancy? Is she near term? Drugs will have different effects given the term of pregnancy and also how long the drug is used for. For instance, a single injection of Valium given late in pregnancy probably will have little effect on the baby as far as causing a birth defect. Also, this doesn’t mean you can’t pick this drug. It would increase the internal conflict of your character, knowing he is giving a potentially harmful drug to this woman.
Benadryl, which is an antihistamine, can also be given IV. It may make the character sleepy but not totally knock her out. Benadryl’s effects aren’t at all predictable. It’s drug category is B.
Then, I thought of Ketamine. We use this in the ER all the time to sedate patients for reductions of fracture and other painful procedures. It has a very predictable effect and can be given IV or into the muscle (IM– intramuscularly). The IV duration is typically shorter than the IM duration.
Here’s some info regarding Ketamine’s use during pregnancy:
Ketamine Pregnancy Warnings
“Ketamine has not been formally assigned to a pregnancy category by the FDA. Animal studies at higher than human doses failed to reveal evidence of teratogenicity or impairment of fertility. There are no controlled data in human pregnancy. Since the safe use in pregnancy and delivery has not been established, the manufacturer recommends that ketamine be considered contraindicated in pregnant women. Ketamine has been assigned to pregnancy Risk Factor B by Briggs et al. as probably compatible.” http://www.drugs.com/pregnancy/ketamine.html.

Heidi offers this perspective:  It would be highly unusual for a doctor to get involved with a patient’s decision to return to an abusive relationship (or prevent it). The intervening party is usually the nurse. In the case you are describing, if the nurse was trying to keep a pregnant patient out of harm’s way, she/he could do many things but the standard is to get a good reactive strip, then give 2mg Stadol and 25 of Phenergan, this combo will generate a nonreactive strip (put both mom and baby to sleep), the doc cannot release the patient with a non-reassuring strip.

Benadryl can also be used to put a pregnant person to sleep, Tylenol pm is highly used but it does not usually affect the strip. But for all intensive purposes, the drug of choice to stop a pregnant person from going anywhere would be phenergan because it is easily accessed, you do not need a witness to remove from the automated drug delivery system, and it is prescribed regularly for nausea and vomiting which are common in pregnancy. Also, pregnant patients are familiar with it and don’t usually question it if the doctor orders it.
Any other thoughts for Sheila?

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A retired middle-grade science teacher and proud grandmother to three, Sheila Hollinghead lives in south Alabama with her husband of thirty years. She has written three books and is seeking publication. She also writes two blogs, one for Christian writers called Rise, Write, Shine!: http://sheilahollinghead.blogspot.com/ and a devotional blog, Eternal Springs:  http://sheilaodomhollinghead.wordpress.com/.

HELLP!: Pregnancy Complications/Heidi Creston

There is a lot of difference between saying you have a cold vs. saying you have bacterial pneumonia. In the world of writing especially medical writing, it is very important that you as the author understand the proper diagnosis and treatment of your character. If it is not clear to you then surely your readers will be confused as well.
Be assured that you will have readers that have either had the condition that your character has, knows someone who has been through it, or like myself, have treated individuals with it. I am more of reader than a writer at this point, and from a readers perspective I will ascertain that nothing will frustrate me faster than an inappropriate diagnosis and/or the incorrect treatment of that condition.
 I focus on the perinatal patient because that is my area of expertise, but I’ve been known to check on a condition if I’m exposed to it in a story. If your story does not center or pivot around the diagnosis and treatment of your character, then it is best to keep everything as simple as possible and not try to overload your reader with information you’ve gathered on the internet. All this being said, I would like to take the time to address the three most prevalent pregnancy related complications written about in general fiction: Preeclampsia (PIH), Eclampsia, and HELLP Syndrome.  
Preeclampsia, Eclampsia and HELLP syndrome are all serious complications that are fairly common and can occur during pregnancy. In fiction these conditions are often used interchangeably by writers, but these are three very different conditions requiring different levels of care in the world of obstetrics.
Preeclampsia is also known as toxemia or pregnancy-induced hypertension.  It presents clinically as high blood pressure and extra protein in the urine after twenty weeks of pregnancy. Signs of Preeclampsia include severe headaches, temporary loss of vision, blurred vision or light sensitivity, upper abdominal pain that usually occurs under the ribs on the right side, unexplained anxiety, nausea and vomiting, dizziness, decreased urine output, blood in the urine, rapid heartbeat, ringing in the ears, fever and sudden weight gain such as more than two pounds a week or six pounds in a month.
Eclampsia is a life threatening condition of pregnancy. Signs of Eclampsia are seizures, severe agitation, and unconsciousness, musculoskeletal aches and pains, involuntary movements, the relaxation phase of deep-tendon reflexes may be longer, apnea, and vision problems. Usually the patient has been previously diagnosed with preeclampsia, but this is not always the case.
The most serious complication of Preeclampsia besides death is the HELLP syndrome. Hemolysis (rupture of red blood cells); EL stands for Elevated Liver enzymes; LP stands for Low blood levels of Platelets. Women who have this syndrome may have problems with bleeding, high blood pressure or liver problems. The most obvious signs of HELLP syndrome are nausea, epigastric pain (pain just below the ribs), or right upper quadrant pain, feeling tired, bad headaches, and there may be swelling that occurs in the face and hands. The compromised body functions can cause seizures, liver failure, kidney failure, heart failure or stroke.
Have you written a scene with one of these syndromes?