Calling the OB for decels..

Pray · Apr 15, 2007

I would not call the doc for one "late" deceleration. Unless you have other changes that are nonreassuring such as baseline changes, fetal tachycardia, or anything that makes you think baby is acidotic like poor variability. Or uterine hyperstim, in which case you want to shut off the pit if it is running, do your other interventions, and call your doc.

As you probably know already, docs and nurses don't always see eye to eye on what constitutes a late, how many you have to have to consider them late, etc. Can you find another OB nurse you trust when you have a question on a strip and get advice from her?

Sometimes a baby just grabs the cord for a few seconds and you get a bad decel. If the problem resolves with your interventions or on it's own, I don't think I would bother the physician. If it recurs, I would definitely be calling so you don't end up with the baby crashing and the dr. saying, "you mean this has been going on and you did not call me?" If it happens once and resolves, I think no big deal. If it recurs a few times, call. Sometimes you get "warnings" and then a big event that doesn't recover. Hope this helps.

weesyanne · Apr 15, 2007

I would call a late decel on a patient. Lates signify placental insufficiency, not cord compression, as would be the case with a variable where the baby temporarily compressed the cord. I always run it by my colleagues and the charge nurse prior to calling. I make sure it meets the NIH criteria for a late deceleration prior to calling.

I know that a lot of Labor and Delivery nurses will disagree with me, and that is their perogative. I worked on an antepartum unit for 8 years and we had to call them. The Labor and Delivery nurses didn't always call them when the patient was in active labor and had a late, but we did not labor patients on our unit if at all possible. It's quite different when you have a patient in the late stages of labor and there is the capacity to do a STAT C-section within minutes if the baby crashes. We had to let the physician know so that he or she could make the decision about whether to transfer the patient to labor and delivery, observe them for a few more hours, or whatever.

If we didn't call an isolated decel and the patient had a bad outcome later that day, guess who's action the management and physicians and risk managment question? The nurse who didn't call the physician when he or she saw an ugly late decel.

I had a physician rake me over the coals for calling him once. I didn't apologize, I simply explained that I had to do it by the hospital policy for antepartum patients on our unit. Sorry, they're getting paid the big bucks to make those decisions, not me. Managment backed me up on it. The patient had severe PIH and delivered a couple of days later and the baby was in NICU for a long time. A good outcome, thank goodness. I won't risk it.

SmilingBluEyes · Apr 15, 2007

For ONE isolated late deceleration that is short of duration? NOPE I would not call the doctor right away. I would accomplish the usual measures to treat lates, position changes, fluid boluses, Os on mom, considering turning off any pitocin on, etc. Also, I would look at her vital signs; did her pressure drop for some reason, like after an epidural----or is she hypertensive and pre-eclamptic---what is her history/medical profile? Be sure you look at the OVERALL clinical picture, FHR and strip! IF the rest of the strip is reassuring, plenty of variability, then spontaneous lates can occur and still, things are alright. A baby with lots of variablity and accels is well-oxygenated and has reserves. A kiddo with reduced or no variability and accels, another story. Upon updating the doctor, I would mention the late decel, describing it with the whole strip, and what I did about it and the fact it was isolated. But, also you need to know your doctor/midwife. If they would want to know, then obviously, you do call. If they are the kind to trust your judgement and the situation is well in hand, then I would not call them.

Also, let hospital policy guide you. If it states you must call the provider in cases like this, then you must. If not, be prepared to take a little heat when/if you call prematurely. Safe is better than sorry, obviously.

Look at your overall clinical picture before calling the doctor. If the late does not repeat and resolves to baseline quickly, take note, when it occured, what you did about it, chart this, and don't worry too much. If they repeat, then it is indeed time to call the provider in to evaluate the situation. Be sure you have the complete clinical picture in mind before you freak out.

weesyanne · Apr 16, 2007

I call any late because I am an antepartum nurse who is one floor up and down the hall from the nearest OR suite in the L&D. L&D nurses don't generally call because they are normally actively laboring the patient when the late occurs. When you have a 28 weeker with severe PIH who exhibits a late and you are the antepartum nurse with 3 or 4 other patients, you have to do what is safest for the patient.

I didn't call a spontaneous decel one night when a lady had it (to clarify, it wasn't a late, she wasn't contracting). She kept having the decels over the course of the next couple of days and the next thing I know, she has a dead baby. There was a knot in the cord. With variable decels, I generally just watch the patient for a while, change her position and base my interventions on NIH guidelines.

I always, always run the strip by a couple of coworkers and the charge nurse prior to calling a physician. Our policy states that the antepartum nurse has to call for any late decel. I'm comfortable with that. If I worked L&D, where the OR was within easy sprinting distance, I would probably react differently.

I just think you should do what in your judgement is the safe thing to do based on where you are working. If you're in L&D and there are a number of physicians nearby and your patient has a late, then maybe you don't call. If it's 1 AM on antepartum and your PIH patient has a late, it's a different story.

That being said, how many pregnant women are probably walking around having all kinds of decels and we don't know it because they aren't on the monitor continuously? We would probably be OK not to call one isolated late on our unit, but our policy (developed with the input of OB physicians and the labor and delivery unit) mandates it.

mitchsmom · Apr 16, 2007

For ONE isolated late deceleration that is short of duration? NOPE I would not call the doctor right away. I would accomplish the usual measures to treat lates, position changes, fluid boluses, Os on mom, considering turning off any pitocin on, etc. Also, I would look at her vital signs; did her pressure drop for some reason, like after an epidural----or is she hypertensive and pre-eclamptic---what is her history/medical profile? Be sure you look at the OVERALL clinical picture, FHR and strip! IF the rest of the strip is reassuring, plenty of variability, then spontaneous lates can occur and still, things are alright. A baby with lots of variablity and accels is well-oxygenated and has reserves. A kiddo with reduced or no variability and accels, another story. Upon updating the doctor, I would mention the late decel, describing it with the whole strip, and what I did about it and the fact it was isolated. But, also you need to know your doctor/midwife. If they would want to know, then obviously, you do call. If they are the kind to trust your judgement and the situation is well in hand, then I would not call them.
Also, let hospital policy guide you. If it states you must call the provider in cases like this, then you must. If not, be prepared to take a little heat when/if you call prematurely. Safe is better than sorry, obviously.
Look at your overall clinical picture before calling the doctor. If the late does not repeat and resolves to baseline quickly, take note, when it occured, what you did about it, chart this, and don't worry too much. If they repeat, then it is indeed time to call the provider in to evaluate the situation. Be sure you have the complete clinical picture in mind before you freak out.

:yeahthat:

(For an otherwise healthy labor pt & fetus, our MD's would actually probably be pretty annoyed if we called for an isolated late unless it was pretty severe &/or long.)

nurse79 · Apr 16, 2007

thanks i was just curious. the other week i had a cervidil induction pt that had like 2 late decels for me. one was in the early morning 8 am ish (fingertins/thick/high) in which we did interventions..with quick resolution. baseline resumed with good variability. the baby looked "flat" at times for me but there was never a time greater than 90 mins without accels. there was another "late" maybe around 1pm ish. which also resolved. i did not get keep the pt, but i heard she had a prolonged decel to 50bpm x 4 mins later in the afternoon..and she went to section. baby did fine, 8-9 apgars..transitioned well. just curious if it is good to call for every or just one "late" that resolves.

I guess safe is def better than sorry.

SmilingBluEyes · Apr 16, 2007

I see alot of that with cervical ripening induction, for some reason. Seems to me, most often, this situation resolves well without much intervention and keeping in line with proper administration of such meds. I can't count how many times I have seen the odd "late" after a dose or two of cytotec.

Susgu · Apr 16, 2007

Glad there was a good outcome for the baby.

I agree with SmilingBluEyes in that one late is NOT a reason to call the OB. However, find out what the policy on your unit is for calling the OB provider.

As far as watching the monitor and assessing your patient, you need to look at patterns and also at what else is going on with the FHR tracing. What is the FHR variability? Are there accelerations? What is the frequency of decelerations? What kind of decels are they? What is the contraction frequency, duration, and strength? What's the mother's cervical exam? How is she positioned in the bed? Take note of the mother's health, as well. Does she have any health conditions? Any problems with this pregnancy? Is she in labor, or is she being induced? Have her membranes ruptured? Is it clear fluid or mec? Etc, etc, etc...

As you can see, there's a lot to keep in mind when taking care of a labor patient! There's definitely and art to it!

If you see decelerations, first thing to do is go into the patient's room and reposition her. Get her off her back! Maybe you also need to give a fluid bolus and some oxygen. What are the mom's vital signs?...All these things like SmilingBluEyes mentioned. If the decelerations resolve, great! If the OB stops by the nurse's station, let him/her know what occurred.

I will say, though, that if you ever have a gut feeling that something is wrong, or you are questioning something and need a second opinion, talk with your fellow RNs and call the OB. Never be afraid to ask and clarify. No one should give you grief for wanting to learn. And if the OB complains, that's his/her problem! He/she probably needs a nap!!!

NPinWCH · Apr 18, 2007

OK, so a spin on this question (allow me to play devils advocate...since our docs play this game ALL the time):

Is 1 isolated late appearing decel truely a late decel since by definition a late decel is one that follows a pattern...contraction - decel - recovery - contraction - decel.....?

I'm not talking about BIG severe ugly looking things, those 20-30 bpm drops after the uc, but those more subtle ones that may even look more "V" shaped, but deep down inside you feel they are late.

Our docs won't call them late unless they are truely "U" shaped and occur with at least 50% of the ucs (by the new guidelines). If they don't meet that criteria then they are considered variables, and therefore pretty insignificant in their eyes.

What are your thoughts?

nurse79 · Apr 18, 2007

i am pretty confused about that as well..asking one nurse she said the same thing "its not late unless it is repetitive" but to me it was a isolated subtle late. soooo are we charting those as variables? even when the decel of the FHR began after the peak if the UC? it was also "U" shaped...

now i'm confused! hmmmm??

Mrs.S · Apr 18, 2007

i am pretty confused about that as well..asking one nurse she said the same thing "its not late unless it is repetitive" but to me it was a isolated subtle late. soooo are we charting those as variables? even when the decel of the FHR began after the peak if the UC? it was also "U" shaped...
now i'm confused! hmmmm??

nope, it's still a late. that's how I'd chart it anyway. but like everyone else has said, look at the whole picture. if everything else looks good and it's not a pattern of lates it doesn't mean you have a compromised fetus.