Linda, a 28-year-old pregnant woman with three children, presents to the emergency department of St. Anthony Regional Medical Center with clinical signs of PPROM. Various tests, clinical assessment, and personal history by the maternal-fetal physician (MFP) on-call indicates that Linda is 18 3/7 weeks pregnant and that, at present, there is no evidence of infection, labor, or fetal compromise. Given this and the gestational age of the fetus, the MFP suggests conservative management consisting of ongoing observation for signs and symptoms of infection, active labor, and/or fetal compromise. While this care plan provides little benefit to Linda, the MFP notes that the potential benefit for her baby can be significant if they can forestall delivery until the baby reaches viability. However, the MFP notes that Linda will have to be on bed rest in the hospital for the duration of the pregnancy because she does not meet one of the criteria for home management, namely living within close proximity to the hospital since her home is in a rural area more than 60 miles away. Though Linda is concerned about the effect this will have on her husband and three children, she nonetheless consents.
After nine days of in-hospital management, Linda becomes increasingly agitated and stressed about her situation and the future outcome of her baby. She complains to nurses of a persistent headache, leg pain, constipation, and hip/back soreness, and has mentioned several times how much a toll this is taking on her husband who must tend to the farm as well as take care of the children. During her visit with the MFP, Linda mentions all this to her and vehemently demands to know what the outcome will be for her baby. The MFP points out that it is hard to know for sure but that if infection and/or preterm labor does not set in there is a good chance that they will get the baby to at least 23 weeks. However, she mentions that the risk of these things occurring is relatively high and that the outcome for her baby even if they get to 23 weeks is still up in the air given the complications that the baby is sure to experience as a result of being born so prematurely. The MFP suggests that if conservative management is too much of a burden on Linda, they could induce delivery now but that her baby would die as a result. Is induction at this time justified under ERD 47? Why or why not?
Linda decides to continue with conservative management despite the burdens she is experiencing. Now at 20 4/7 weeks pregnant, though, Linda spikes a fever, has uterine tenderness, vaginal discharge, and fetal monitoring shows an increased fetal heart rate, all signs of chorioamnionitis. The MFP informs Linda of the change in her condition and suggests that they could initiate antibiotic therapy as well as administer tocolytic drugs but that the likely outcome for her baby is not good given the gestational age and the risks to Linda are significant. After discussing the options available to her with the MFP, Linda decides to induce delivery now even though her baby will die as a result. Is induction at this time justified under ERD 47? Why or why not? (Courtesy of Dr. Michael Panicola, SSM Health Care, St. Louis, Mo.).