FHR, hypotension, birth experience, PLEASE HELP

[RachelScurlock]

I will try to keep this as brief as possible... I'm a nursing student who recently gave birth. I've have two other children so I'm no rookie, but there were several things about this birth that concerned me, so I got my medical records and fhr strip, and now I have some serious questions/concerns that keep eating at me. I would SO appreciate some experience/feedback, I want to know if there's any cause for concern and if my care was appropriate while I was in labor.

I have two concerns... biggest one is hypotension. After epidural placement, had some hypotension that passed after 20 minutes, not too worried about that episode. A few hours later, I requested a top-up. Right before the CRNA arrived, nurse put me on my back to check cervix, BP dropped to 104/37, then 106/42, now CRNA comes in and gives me more meds, BPs continue to be low, 98/55, 106/37. This went on for a total of 30 mins from start to nurse coming in and hanging new IV bag. Pressures immediately went up to 120/45, 112/44, then right back down to 108/45, 94/55, then not read again until 20 minutes later at 105/38. Twenty minutes after that last reading, the nurse came in and gave me an IV bolus, BP isn't read again until an hour later, 112/72. I was never given ephedrine and response time was 30-40 minutes with these ongoing pressures. I'm wondering if I should be concerned about my baby having some hypoxia due to these blood pressures. My normal pressure was 120/70. During this time period, my IUPC came out, so contractions weren't picking up, but my baby began to have some shallow decels, cant tell if early or late due to no contractions to compare. Variability decreases but stays 6bpm (moderate), and accelerations decrease and are almost absent for about an hour. Then, she comes on and off the monitor, the tracings I can see in between have moderate and some minimal variability, but this is after BP is resolved. It continues for quite a while. One more episode after this, nurse puts me on my back for 4 mins straight to check cervix, bp plummets to 120/37, and stays low for 20 mins or so.

After this 2-hour-long episode, someone else came in the room and suggested checking me for ketones. They didn't tell me why. I was fasting according to hospital rules, and they knew I'd been there for 13 hours at this point. Why did they check me for ketones? Do all laboring women who are NPO develop ketones, and what is the protocol for checking for them and administering dextrose? Mine came back large and they gave me dextrose.

So... was care appropriate? Should I be scared? Why weren't they worried? And is it ok to put patients in supine position after epidural? I thought that was a big no-no, how dangerous is this?

I would appreciate some feedback so much. I just want to know what happened, know if I should be worried.

[Red Kryptonite]

I wish hospitals would get on board with evidence based practices and physiological birth. NPO, continuous EFM, placing laboring mothers flat on their backs.....grrrr....

I'll let others with more experience and training elaborate, but it's this kind of thing that makes me want to become a CNM and lead a revolution to finally get this country out of the Victorian-age inspired dark ages of birth that for some reason we choose to continue to live in.

[RachelScurlock]

I appreciate your reply... I agree. I initially had a midwife who delivered at the hospital, but she left the practice halfway through my pregnancy. She delivered my older daughter, so I thought it would be safe to go with the OB/Gyn at her practice. I trusted the hospital and just went along with things, wish I hadn't.

[ixchel]

I know how hard it is to make sense of a birth that wasn't what you expected. Questioning everything, wondering if your experience wasn't handled as it should be.... It's hard. After my experience, I would look at my daughter and feel so many conflicting emotions, and the one that crushed me most was guilt - guilt that I should feel joy at her but couldn't.

I agree with Red that EBP needs to be brought in more for hospital births, but for the time being, it's not. As for the rest, I really can't comment because I don't know enough to, and giving medical advice here would be inappropriate.

I do, however, encourage you to reach out on forums for women who have had births that have been traumatic, difficult, or resulted in special needs babies. I wish I could tell you that your "what ifs" will fade with time, but I can offer you hugs, and condolences for an unexpected birth outcome. It's okay to grieve your birth. Please don't forget that!

[klone, MSN, RN]

I'm sorry, we are not allowed to give medical (or legal) advice on these forums.

I would say that, in my experience as an L&D nurse, we would not give ephedrine for those pressures unless the baby's heart tones were tanking, or the patient was symptomatic. Those pressures are simply not anything we would typically worry about unless the mom was pre-eclamptic and ran in the 140s/90s as a baseline. If the baby was hypoxic, it would have told them so via the EFM strip.

[JessicaDanielle]

I would say it's difficult to get any sort of idea of what the efm was truly showing by the description of an inexperienced reader. If you have questions about the care you received, I suggest asking your practitioner as they would be to discuss your concerns. At this point unless you're planning on suing, I'm not sure what you have to gain from second guessing the care you already received if there was no harm to yourself or your child. If you were not comfortable with the standard of care you received this time, I would suggest going to a different doctor/hospital.

[RachelScurlock]

I appreciate the replies so much. I'm not seeking medical or legal advice per se; I just want to know if this is standard for care or if I should be a little worried. I have attempted to talk to my ob/gyn and the charge nurse at the hospital. Ob/gyn won't talk to me directly, he has had nurses call me back and give me short, unhelpful answers (they don't have the time, and they assume I'm just a neurotic mother - they weren't there while I was in labor and haven't reviewed my chart), and charge nurse briefly explained a couple things away but wouldn't get into specifics. I tried to ask her what the guidelines were for BPs and when they worry about hypoxia, and why my IUPC was out for so long and the significance of the fhr during the low bp period, and why they suddenly decided to check for ketones after 13 hours, etc. I was also told a few times that someone's always watching the fhr monitors, not sure if that's accurate either. The nurse was the only one reading and charting them, I'm wondering what the level of surveillance is on the heart monitors as well.

[klone, MSN, RN]

Most places have central monitoring. All the labor rooms and their efm strips are on a bank of screens in the main nursing station where the nurses and physicians hang out. So yes, that is true that someone 'a always watching the strips. On breaks we would eat lunch and look at the strips like we were watching a good movie.

[JessicaDanielle]

Labor nurses are almost always in front of the monitors if they're not in the room laboring with you. Your bps alone wouldn't not indicate fetal hypoxia, which is why someone would need to interpret the strip to know. In all honesty our parameters for ephedrine are for systolic of >85 or decreased MAP. We tend to not focus too much on diastolic for ephedrine parameters.

[RachelScurlock]

Thanks for the info... my MAP did fall, it was in the low 60's and a few times was a little below 60, that's what had me so concerned later on (I didn't know any of this until much later, they turned the alarms off in my room)

[ontheway2crna]

Your bp did not "plummet". Plummeting is going from a SBP of 180 needing all sorts of drips to maintain under that to a 40/20. Ive seen that. Perhaps with more nursing education and real nursing experience your worrying will fade one day.

[JessicaDanielle]

I'm not sure what you're looking for. I know you're worried, but I don't think you have much to worry about