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.
I really hope so. I guess main concern is MAP being in low 60's for a prolonged period of time. I don't see how the placenta could have been properly perfused with the MAP dropping that low. From my understanding of MAP, 60 is the minimum just for blood supply to vital organs, and there was a >20% decrease in BP, which is, from everything I have read, considered a concerning hypotension. I'm also still curious as to norms for checking for and clearing ketones w/ dextrose during labor (at what point do they check for those? since I assume everyone would have ketones due to NPO policy), and the normal standard procedure for placing a pt in supine position after an epidural has been administered. I had two nurses do that, I argued with them at first but they assured me it was fine, and of course dizziness and low BP ensued.
I guess what I'm looking for is info. I want to be well-informed about normal OB nursing practices, so that I know what I'm looking at
Also, blood pressure can vary by a lot depending on your level of activity. A healthy young woman will have a SBP that hovers around 100-110. I honestly don't trust those diastolic readings you got. If they didn't take manual BP readings with a person doing it correctly with a well-fitting cuff, MAP really is pointless to calculate without knowing how reliable that diastolic number is.
Specializes in mom/baby, EFM, student CNM, cardiac/tele.
I would recommend reading AWHONNs Maternal Newborn Nursing book. Also keep in mind that things seem like a bigger deal when you're a nursing student. With a little more knowledge and real life experience things may seem very different.
Thank you for the book recommendation - I will definitely look into it. I was a CMA for years (CMA nothing compared to a nurse, but I spent years with way more responsibility than most CMAs, and a lot of self-educating), my mom is an RN, and I have other family members in the hc field, I grew up around it.
Only outcome I saw that worried me, at first, was my daughter being blue when born, and she had what appeared to be nystagmus for a couple days after birth, which went away. Never saw that with either of my other kids. Also, heart tones were completely lost for about 80 seconds before she was born; I was told it was probably from her moving down so far, but was extremely stressed out and irritated that I held her there without any heart tones on the monitor just so the doctor could slowly put his gloves on and get some extra sheets out. I just didn't trust the care that was given, and nothing was explained to me along the way, so that's why I dug deeper. What I'm trying to figure out right now, is if I should be worried about hypoxia (obviously would have been mild) that may cause later issues in development, which is entirely possible from my research.
Specializes in mom/baby, EFM, student CNM, cardiac/tele.
I think a lot of your fears could have been resolved if your healthcare team had provided better communication to you. I'm sorry it wasn't a better experience for you. Giving birth can be scary as so many things can go wrong. This is one of the reasons I've chosen to be a CNM, as I saw room for improvement and wanted to provide a better experience for people. If you choose to further your education in the healthcare field, hopefully you too can use this as a learning experience to provide better care to those in need. Many pursue nursing to do just that!
Blue babies and nystagmus as actually pretty normal. The blue goes away immediately, as you saw, and sometimes nystagmus can last for months. Babies will also get blue limbs long after birth if they are cold. This hangs around months after birth. It's a "safety mechanism" of sorts that happens because the baby's circulatory system is programmed to send more blood to vital organs when they get chilly. So if you ever see your baby get blue arms and legs, think cold, not hypoxia.
You are welcome to PM me if you do feel like emotionally, your birth has left you feeling not-so-good. Again, it is completely normal to mourn a birth that wasn't what you expected. You are not alone in this, and if you're feeling like you are, you should connect with others who have experienced it. (((Hugs)))
Specializes in mom/baby, EFM, student CNM, cardiac/tele.
I would also recommend reading about newborn transition after delivery. It's amazing to know that fetal oxygenation is only around 60% in utero and after delivery, during transition, it can take newborns up to 10 minutes to obtain normal oxygenation! It is a fascinating process and well worth reading about.
Specializes in Nurse Leader specializing in Labor & Delivery.
Nystagmus is VERY normal for several weeks after birth. Newborn babies' neuro development just isn't 100% when they're first born.
And yes, it's very normal to lose FHTs right before the baby is born, due to it being in the birth canal.
Honestly, what you describe sounds like a very normal delivery to me. It sounds like what was lacking was communication. Truly, I would try not to worry about your baby's neuro or cerebral function.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you for the book recommendation - I will definitely look into it. I was a CMA for years (CMA nothing compared to a nurse, but I spent years with way more responsibility than most CMAs, and a lot of self-educating), my mom is an RN, and I have other family members in the hc field, I grew up around it.
Only outcome I saw that worried me, at first, was my daughter being blue when born, and she had what appeared to be nystagmus for a couple days after birth, which went away. Never saw that with either of my other kids. Also, heart tones were completely lost for about 80 seconds before she was born; I was told it was probably from her moving down so far, but was extremely stressed out and irritated that I held her there without any heart tones on the monitor just so the doctor could slowly put his gloves on and get some extra sheets out. I just didn't trust the care that was given, and nothing was explained to me along the way, so that's why I dug deeper. What I'm trying to figure out right now, is if I should be worried about hypoxia (obviously would have been mild) that may cause later issues in development, which is entirely possible from my research.
Congratulations on your new addition!
I am so sorry you had a stressful delivery. I think that has much more to do with your anxiety than anything medical. I think if you had more confidence in the team where you delivered...your experience would have been different.
As others have said we cannot give medical advice. It is impossible to actually know what was going on without looking at the chart and being there. Even reading a chart is playing Monday morning quarterback.
What you have described is all perfectly normal findings...whatever :"normal" means. It is not against any medical customary rule to lie flat after an epidural...actually it is the treatment if the patient experiences hypotension which is not uncommon after administration of the meds. It is not uncommon for cyanoisis after birth and nystigmas is also a normal finding in newborns.
Hypotension...define hypotension. Well hypotension is usually below the "normals...whatever that is...a "normal" B/P is usually between 90/60 mmHg and 130/80 mmHg.
Now just because a B/P is low....doesn't mean it requires immediate intervention. A usual guideline is a SUSTAINED B/P less than 90 with a MAP SUSTAINED below 60. In treating a low B/P you look at all possible contributing factors and treat accordingly. You change the patients position...You administer fluids before resorting to meds which have consequences themselves...like vasoconstriction which could further decrease oxygen delivery.
It sounds to me that, while a stressful delivery, you have a healthy baby. ((HUGS)) Breathe...you are going to drive yourself crazy with worry. Relax and enjoy your baby.
Being a nursing student can be really stressful, because you know *just* enough to be concerned, but not enough to know if there is really a problem. I would probably be doing the exact same thing you are doing. But I agree with the previous posters; what you are describing does not sound concerning or particularly out of the ordinary.
RachelScurlock
9 Posts
I really hope so. I guess main concern is MAP being in low 60's for a prolonged period of time. I don't see how the placenta could have been properly perfused with the MAP dropping that low. From my understanding of MAP, 60 is the minimum just for blood supply to vital organs, and there was a >20% decrease in BP, which is, from everything I have read, considered a concerning hypotension. I'm also still curious as to norms for checking for and clearing ketones w/ dextrose during labor (at what point do they check for those? since I assume everyone would have ketones due to NPO policy), and the normal standard procedure for placing a pt in supine position after an epidural has been administered. I had two nurses do that, I argued with them at first but they assured me it was fine, and of course dizziness and low BP ensued.
I guess what I'm looking for is info. I want to be well-informed about normal OB nursing practices, so that I know what I'm looking at