late d-cels, but good variability

  1. I wanted to see your opinions on this matter. I had a pt last night that was a G1P0 at 41 wks being induced for oligo, the order was prostin gel x2 then pitocin in the AM, well right off the bat, just about every ctx yielded a late d-cel, HOWEVER, IVF bolus and turning the pt resolved the lates for a period of time, of course I contacted the dr, and we switched from the prostin induction after washing it out to low-dose pit, the pattern resolved, had excellent reactivity and average variablity, the pt was not favorable in the least, 2/20/-3 SO, after a while the lates came back, IVF bolus PIT Off, and turning the pt, they resolved, called the dr again, she came and looked at the pattern it was GREAT, after a while, AGAIN with the lates, all the while having average variability responded to scalp stim, etc......I dealt with this pattern all night long, never turning the pit back on knowing full well she'd be cut in the AM. So i left around 7:30am after giving report and came back the next night to see what happened, she continued having lates off and on throughout the am and about 9 they made the decision to proceed with the section, apgars 2,8. and that night baby went to NICU for fast breathing, and a gunky looking x-ray, mom was GBS pos, treated with AB's, and light mec noted at delivery, ANYWAY, it was just a very strange questionable pattern that gave me a headache and I charted my butt off all night long, meanwhile trying to reassure the mom and family about what was going on and warning them about needing a c-section.....I doubt doing the c-section would have made a difference earlier, but still makes ya wonder....it wasn't the kind of pattern that needed immediate c-section, but still....anway, what do you all think?? Shelley
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  2. 17 Comments

  3. by   mark_LD_RN
    you discribe a pattern i seen before while it is not always bad, i have seen good outcomes with it and bad. just as much so I have seen pretty good looking strips and delivered a bad baby. you did all you could. we will never know if an earlier section would have changed the outcome.
  4. by   canoehead
    Lates that keep coming back make me want the baby out- I'm usually pretty easy going but that just spells trouble to me, even with good periods inbetween.
  5. by   anitame
    I HATE lates. I personally think they were created just to torture poor innocent well-meaning L & D nurses. I have spent shifts like that Shelley and I hate them. You are afraid to not watch the monitor every second for fear of missing something that needs immediate attention, and YOU KNOW they'll end up being sectioned. It sounds like you did all you could, I definitely would have left the Pit off too.
  6. by   SmilingBluEyes
    Lates are NOT always meaning csection. (but I agree,they mean baby needs out SOON). I had a labor pt. the other night, baby had a couple VERY nasty 4-5 minute lates down to 60s from baseline of 140s. I turned off the pit, put on O2, Bolused her 500cc LR and turned her on the OTHER side (her right this time) and it stopped. She pushed the baby out on her side. It must have been a serious cord compression situation...dunno. Apgars were 9/9. No cord around the neck or anything like that.....

    But yea those lates will DEFINATELY cause us to take notice. The lates you in which you may have hope have GOOD variability in baseline and during the decel....and do recover. They are most often in the PUSHING or TRANSITION phase of labor, too, not early on, obviously. Recurring lates or ones with a flat baseline......OHHHHHH those scare me the MOST! Definately will keep us on our toes.
  7. by   luv l&d
    a good case for fetal pulse ox, then you would know how that baby is really doing.
  8. by   OBNurseShelley
    that would have been a great idea, BUT, the patient was not rupturable, she was 2/20/-3 and VERY posterior, believe me if they could have they would have AROM'd in a second! Do you use the pulse ox frequently? MOst of our private docs wont' do it, but the residents use it quite frequently..
  9. by   finallyRN
    I agree I have had strips like you described where the eventual out come was still good. I thingk the baby wanted out of there but it wasn't necessarily an emergent situation. it is hard to say if the outcome wouldn't have been the same if the baby had come out sooner. As long as you charted all of your interventions and that the doctor saw the strip then you have done everything you possibly could have.

    For those of you who use fetal pulse ox, do you find that it correlates to overall out come? Does a fetus with a bad fetal pulse ox turn into a bad newborn?
  10. by   OBNurseShelley
    NOT necessarily. I've seen it work BOTH ways, a good looking pattern end up with low pulse ox, and we do a c-section and baby appears fine, either way baby probably needed to come, and vice versa, just cuz the pulse ox is good, doesn't mean you ignore your pattern, and dont do interventions, it's important to remember it's just ANOTHER assesment tool, NOT a definitive answer
  11. by   SmilingBluEyes
    agree w/shelly. won't expound.
  12. by   at your cervix
    It is so hard!!!! All said monitor strips never tell the real story!! I had a pt a few weeks ago that was G1P0, started having prolonged variable decels at 8-9 cm, MD had her push, unable to delivery baby and FHR dropped to 40 x 10 min, rushed her back to OR, put under general anesth., had the baby out in less than 5 min from the time we decided to do the section, FHR was still down in the OR, baby came out screaming, 9/9 apgars. Then next day, had a strip with great LTV, great accelerations, and not so much as a variable decel-had to do a full code on the kid!!!!!!!!!!! It's is just a guessing game sometimes, don't ya think?
  13. by   OBNurseShelley
    ABSOLUTELY!!!!!!!! One can never tell, until that kid hits room air, what will happen, that's why no matter what the pattern looks like, i try to always be prepared with my o2 and suction ready.........
  14. by   SmilingBluEyes
    Yea I have this saying when I precept or orient newcomers:

    *Expect the absolute worst scenario; HOPE for the best. *

    I live by this in OB and "pretend" the kid coming is my "worst-case scenario" because I have seen them come out after a PERFECT strip, 9/9 apgars, CRUMP on me! Ya have to be CAREFUL!

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