Butterfly McQueen made her acting debut as ‘Prissy’ the flighty maid of Scarlett O’Hara in Gone With the Wind. Her most memorable line was “I don’t know nothin’ ’bout birthin’ babies!” Butterfly would not make it as a correctional nurse where 6-10% of female inmates arrive pregnant and labor and delivery are high-risk and unpredictable.

The Prison Journal recounts legal issues regarding medical care for pregnant inmates with some rather shocking recountings of court cases; several involving poor nurse judgment regarding pregnancy, miscarriage and labor. If you care for female inmate, you need to be able to determine signs and symptoms of miscarriage, evaluate fetal heart tones and determine if a woman is in active labor requiring transfer to a hospital. Here are some key points to consider.

Miscarriage

In Ferris v. County of Kennebec (1999) a pregnant inmate experienced vaginal bleeding and reported this to the nurse who determined that this was not a miscarriage but menstrual blood based on the patient’s pulse rate. The patient was sent back to her cell where, after several hours of extreme pain and continued bleeding, she miscarried.

Any vaginal bleeding in a pregnant woman needs investigation. Although first trimester abortions are more often related to genetic abnormalities, second trimester events are linked to maternal conditions including use of cocaine and acute infections. A second trimester miscarriage can involve significant blood loss and pain. Retained fetal parts must be surgically evacuated to avoid infection. Miscarrying women need continuous monitoring and intervention. If the mother is Rh negative, RhoGAM may need to be administered. Therefore, a miscarrying pregnant inmate requires a nursing assessment and continuing progression monitoring until a medical determination is made for transfer to an acute care facility.

A Brief Overview of Miscarriage Management

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Fetal Heart Tones

In Coleman v. Rahija (1997), the patient was known to have prior high-risk pregnancies and was transferred to the prison infirmary when she developed extreme abdominal pain. She was observed but no vital signs, vaginal exam or fetal heart tones were documented. The patient was sent back to her cell and was later found on the floor in extreme pain. She was then transported to the hospital where she delivered prematurely.

Every facility detaining females should have a fetal heart monitor and all nursing staff should be familiar with when and how to use it. If a pregnant woman accesses the health unit for any reason, fetal heart tones should also be assessed. Normal fetal heart rate is 120-160 bpm. This rate can slow or speed up when the baby is in distress. Record fetal heart rate in the medical record and follow trending as with other vital assessment findings.

Using a Doppler – although this is a demo by a mother, she does a good job of showing pitfalls and providing distinguishing sounds

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Active Labor

In Staten v. Lackawanna County (2008) a 6 months pregnant inmate complained of pressure in her pelvis. She was evaluated in the jail medical unit. The nurse determined she was not in active labor yet and the patient was relocated to a camera cell. Correctional officers did not respond to information from the patient that her water had broken and that the baby was crowning. The nurse did not continue to monitor the patient once she had left the jail medical unit. The baby was born in the cell.

Active labor can be difficult to determine in this patient population. Contractions that are strong and last from 45-60 seconds at a frequency of 3-5 minutes indicate the active labor stage. This is the time most women are admitted to the hospital. However, high risk pregnancies or women with histories of difficult or precipitous labors need to be closely monitored earlier. In all cases, if a patient indicates that she is in labor, is assessed in the medical unit and sent back to her cell to progress further, she should be actively and regularly monitored by healthcare staff until a determination is made to admit to the hospital. It is inappropriate to have security staff or the patient as sole monitors of labor progression.

Nurses are the first point of contact with healthcare in a jail or prison. Correctional nurses must initiate action when a pregnant patient appears to be in labor. The high risk nature of the majority of pregnant inmates requires a high level of suspicion that labor may be progressing even if the woman is not in the final weeks of pregnancy. Here is a good basic review of the stages of labor.

The cases reviewed have some common themes

• The nurse did not believe the symptom reports of the patient
• The nurse did not appropriately assess the patient
• The nurse did not intervene on behalf of the patient

Have you had experiences with labor and even delivery in your correctional setting? Share your experiences in the comments section.

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