Do "ominous" fetal heart tone strips ever improve if you wait awhile?

[beachmom]

Had a mom come in with decreased fetal movement. Hooked her up to monitor the fetal heart tones. They were 160 with minimal to absent variability with a couple lates. The doctor waited for hours before deciding to do a section, hoping they would improve. Biophysical profile was 2, and stimulation had no affect on the heart rate.

Baby came out with no heartbeat, apgars 1,5,5,7 (1,5,10 and 15 minutes). Had to put baby on a vent and ship her to the bigger hospital in another town. Happily, we have heard she is responding well to therapy. Hope she continues to do well in the future.

We had a similar strip in the past, and the doctor called the big hospital neonatologist who said to watch and wait, and we lost that baby. Another similar one, the doctors watched until the strip went sinusoidal, then did crash C/S. At birth they found it was an abruption and improperly implanted cord. That baby was odd. For the first two days his heart rate was 60-110, respiratory rate was 12-20. On the third day his heart and respiratory rates improved to normal, and he started eating. Went home a few days later.

When the strips are that bad, have you ever seen them improve in utero and baby is fine?

Also, with this kind of strip, is there probably brain damage, or can they be OK? I never get to hear about our babies in the long-term. Often wonder how they turn out.

In my opinion, they should section sooner, but I've only been in LDRP a couple years.

[tntrn, ASN, RN]

I'd say they rarely improve, and where I work, we don't give the chance. The problem is that you don't know how long they've been that way and if there is an compromise in a baby's longterm outcome, there's no way to know if it occurred before they ever arrived to the hospital or if it occurred between the time they arrived and when they got sectioned.

The lawyers will be quick to blame it on the latter time slot, however...always.

[SmilingBluEyes]

Many cases have been successfully sued based on "lack of timely action to deliver compromised fetus". If your strip is all that "ominous" it means prompt delivery is indicated. Check out http://www.nso.com and see some of the case studies there......most refer to lack of timely action in those that are successfully won for the plaintiff.

[babyktchr, BSN, RN]

holy cow.....absent variability AND lates with no improvement with intrauterine resuscitation and BPP of 2 and we wait to see if it gets better? If only the fetal monitor could spell out HELP ME.......

[SmilingBluEyes]

...it just did. The baby was CRYING for help on that strip in the clearest way it possibly could!

[SmilingBluEyes]

I hope whoever was caring for that labor patient documented her care and the use of chain of command. That is about the best I can say here.

[klone, MSN, RN]

If intrauterine resuscitation efforts do improve the strip, it's recommended that you actually wait a bit before sectioning, as the intrauterine resuscitation will improve outcomes more than extrauterine (if it's effective, of course, the big caveat).

We had a mom come in at 28 weeks, with a known complete previa that had abrupted. She was COMPLETELY covered, from neck to feet, in blood. Her initial BP was 42/28. She was absolutely gray, but responsive. The ER nurse who brought her up to us stayed to help and quickly got two IV lines in her, and we pumped her full of fluids. Initially, FHTs were in the 60s, but a few minutes after giving her some fluids, it went up into the 120s, and actually had some variability.

We sectioned her right quick, but the OB said that it was those extra few minutes it took (had to call in the OR staff), that actually helped the baby to do better than he would have done if we had sectioned her the minute she got there.

[beachmom]

You have to ask if the baby is better off in the mom or out of the mom. With bad heart tones and a BPP of 2, the baby is obviously better off outside. Afterwards one nurse said a BPP of 2 means a "dead baby with a heartbeat."

I wasn't the nurse, but some day I might be in that position. I'm not good at standing up to doctors, especially when I've had two years experience in LDRP, and they have had 30. But if I KNOW that waiting won't improve the baby, I will stand up. Thank you all for your opinions.

[RNLaborNurse4U]

Also - sometimes using terbutaline to increase maternal cardiac ouput will benefit with increased fetal cardiac ouput, when utilizing intrauterine resuscitation. Of course, since terb is a drug, we cannot just go giving it willy-nilly --- need either standing orders or an MD/CNM order to give it.

[SmilingBluEyes]

Using terb can help, but you have to k now when/how soon baby will be born. I always ask the physician if he/she wants terb. It's a good idea if you have lots of uterine activity, clearly, but then you have to watch out for bleeding after delivery, esp if it's very prompt.

One of the hardest things is standing up to physicians.It's never easy, I know. But you have to ask yourself, would you rather stand up to a dr or to a jury in a trial?

I have had to do it a few times in my career and it was not fun. But it was worth it.

[NurseNora, BSN, RN]

Once again, you have to look at the entire picture. What was the 2 on the BPP for? If it was for amniotic fluid volume, whatever is going on is acute. If it's for something else, it's likely a chronic problem. (Over stressed babies shunt circulation to brain, heart, and adrenals and away from "nonessential" organs like the kidneys. This results in decreased urine output and ultimately in reduced amniotic fluid volume)

What was the doc doing other than waiting? Were there various tests going on to try to find a cause for the scary strip?

There's a strip in the AWHONN Intermediate FM class that shows a similiar situation, even a BPP of 2 (for amniotic fluid volume, showing an acute problem). The doc tried an induction, but finally delivered the baby by C/S as the strip got worse. The rest of the story? Mom was a diabetic who took her insulin in the morning, but hadn't had lunch since she was at the doctor's office and even though they did a blood sugar on Mom, no one must have looked at it because her sugars were low. Baby's sugars were scary low even after being given a sugar bolus. This baby's strip would have improved if only someone had noticed the low sugar and fed Mom.

This is not a situation that comes up often, we do tend to pay attention to the results of the labs we run. But it is an example of a bad looking strip that can get better if appropriate action is taken.

Was Mom having an asthma attack and unable to adequately oxygenate herself? Is she severely anemic? Anything that compromises Mom will also compromise the baby and should be dealt with (if possible) before moving to an emergent C/S.

[beachmom]

once again, you have to look at the entire picture. what was the 2 on the bpp for? if it was for amniotic fluid volume, whatever is going on is acute. if it's for something else, it's likely a chronic problem. (over stressed babies shunt circulation to brain, heart, and adrenals and away from "nonessential" organs like the kidneys. this results in decreased urine output and ultimately in reduced amniotic fluid volume)

i don't know what the "2" on the bpp was for

what was the doc doing other than waiting? were there various tests going on to try to find a cause for the scary strip?

doc was sleeping, didn't want to come in for c/s (in my opinion). i wasn't there during the labor. i came on afterwards, so i'm not sure what all they were doing.

there's a strip in the awhonn intermediate fm class that shows a similiar situation, even a bpp of 2 (for amniotic fluid volume, showing an acute problem). the doc tried an induction, but finally delivered the baby by c/s as the strip got worse. the rest of the story? mom was a diabetic who took her insulin in the morning, but hadn't had lunch since she was at the doctor's office and even though they did a blood sugar on mom, no one must have looked at it because her sugars were low. baby's sugars were scary low even after being given a sugar bolus. this baby's strip would have improved if only someone had noticed the low sugar and fed mom.

mom had gestational diabetes, but her blood sugar was fine here. baby was born with low blood sugar and was lga.

this is not a situation that comes up often, we do tend to pay attention to the results of the labs we run. but it is an example of a bad looking strip that can get better if appropriate action is taken.

was mom having an asthma attack and unable to adequately oxygenate herself? is she severely anemic? anything that compromises mom will also compromise the baby and should be dealt with (if possible) before moving to an emergent c/s.

i thank all of you for your answers!