FHR tachycardia dilemna-sorry if its long but i need advice!

Specialties Ob/Gyn

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Specializes in ob gyn.

I have 27 yrs experience as a L/D nurse and was totally stymied last night.i was in charge over the ob'gyne floor with a fairly new nurse working in the labor room. i should add i work at a 200 bed community hospital.

Had a pt come in at 10pm for a routine rule out labor check. she was complaining of backache. G1po, 17yr,37.5 weeks- fhr was consistently 140-150's with moderate variability, accels etc. the strip looked good. we had to keep her b'c her physician is the type who doesnt like to be bothered thru the night and she lived and hour away. she was NOT in labor, proceeded to fall soundly asleep. At 0405 the fhr made an abrupt change from 128 to 225 and continued that way for 9 minutes. the nurse taking care of her called me back and I figured there was a monitor issue and proceeded to fiddle with it, then i got a doppler and listened and it was indeed 225. the moms vs were stable her temp was 98.2. i turned her to her left side and after about a minute the fhr rate went back to 140's. called the dr to let him know. 5 min after that, it did it again, this time staying tachycardic for 1 3/4 hrs. called the dr, who told us to "quit waking him, what was he supposed to do the baby was just playing around" ran an iv of LR, o2 via facemask which the pt refused to keep on continually, changed her position from R to L to semi and back again, nothing seemed to help. Called the local tertiary care center to consult with a RN there who said she had never had such a thing either, suggested all the interventions i had already done. called our nsg supervisor who also had no new insights. I then called the MD and told him i was NOT comfortable with this, and i did NOT like it and i wanted him to come in RIGHT NOW.. he waffled a bit and then said he would transfer the pt to tertiary care hospital. Got everything ready to go and the darling 17yr old in all her wisdom REFUSED to go. while we were trying to change this childs mind had a US done(which took the tech 70 minutes to get in-she was on call) she came running out to us saying the fhr was in the 80's, she "WATCHED it drop, the baby had no movement and no fetal respirs... we turned pt to left side, MADE her put the 02 back on ,fhr was 140's and the tech proceeded with the BPP to which she gave an 8/8

i asked her HOW she could do that given the 'distress' she witnessed and she gave me some convoluted story and stuck with her 8/8

the dr called back in to see if she was gone, we told him she wanted to sign out AMA to go home to sleep, and he said he was coming in,. called the ped on call to let him know what was happening, he came in for the 'just in case' and the ob finally showed up 1.5 hrs later. when i LEFT this am the dr was considering sending her HOME and scheduling a fetal echo the following day at the tertiary care center. he decided daily nst's would be enough.

i havent called back in to see what REALLY did happen today BUT my QUESTION IS,.... have any of you encountered such prolonged fhr tachycardia and WHAT DID YOU DO?

THANKS for sticking with me in this saga! im anxious to hear your responses.

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Wow, ... just a student, but he let her go?! and all this at 37.5 wks? I sure hope this one ends well.

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Specializes in Community, OB, Nursery.

Probably at my place m(big teaching hospital), they would have sectioned her for distress, if the fhr was truly in the 220s. It doesn't take long for heart failure to ensue at rates like those - I'm sure that's not news to you as you've got way more experience than me in these things.

It sounds like the kid was trying his best to compensate. And if someone saw the HR drop on u/s to the 80s, perhaps they saw the other end of it? I have seen FHRs be labile like that when there's something funky going on w/ the cord (knot? nuchal? prolapse?) and the sympathetic/parasympathetic nervous systems are going bonkers trying to figure out how to compensate. We had one kid that had something similar going on and when they finally sectioned mom, he had the cord wrapped around his face making an oval - 4 times.

I will be interested to see what happens - please keep us updated.

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Specializes in Antepartum, L&D, Postpartum.

Thanks for sharing your experience :up:

Could it be Wolff-Parkinson White (WPW) Syndrome or some other type of SVT? I haven't seen anything like that on EFM (thankfully!) but we had a 12-hour old babe who on a vitals check had a heart rate in the 220-260s and had to be cardioverted (first tried the ice-bag to the face and then I think adenosine was what worked).

I remember reading somewhere that when fetal SVT is diagnosed in utero they often give meds (digoxin & other antiarrythmics) to mom to try and cardiovert before delivery. I think treatment often depends on the etiology, gestational age and severity (intermittent vs sustained) of the SVT. Sustained SVT can lead to congestive heart failure or hydrops, and can put the fetus at risk for demise.

Sounds like you did everything right to let the MD know that he needed to come in and assess the situation.:yeah:

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Specializes in Staff nurse.

Saw a FHR of 200-210 DURING contractions when I was a tech...told the RN who came in, heard and called the doc. He came in (from home, this was a small Army hospital in the 70s) and the heart rate behaved for him for a short time. My shift was done, and when I came back that night, pt. had had a section, delivered full-term baby who was albino. Doctor actually apologised to me next time he saw me...for not believing me.

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It sounds like an SVT. I've seen it twice in utero, and both behaved as you described. One pt was pre-term and we did cardiovert with drugs for the mother. Extremely interesting and a very good learning experience. We kept her in our high-risk unit. The other was term and we delivered her. I don't know because of course, I wasn't there, but I would be willing to bet money, this is what was going on with your patient.

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Specializes in Med-surgical; telemetry; STROKE.
I have 27 yrs experience as a L/D nurse and was totally stymied last night.i was in charge over the ob'gyne floor with a fairly new nurse working in the labor room. i should add i work at a 200 bed community hospital.

Had a pt come in at 10pm for a routine rule out labor check. she was complaining of backache. G1po, 17yr,37.5 weeks- fhr was consistently 140-150's with moderate variability, accels etc. the strip looked good. we had to keep her b'c her physician is the type who doesnt like to be bothered thru the night and she lived and hour away. she was NOT in labor, proceeded to fall soundly asleep. At 0405 the fhr made an abrupt change from 128 to 225 and continued that way for 9 minutes. the nurse taking care of her called me back and I figured there was a monitor issue and proceeded to fiddle with it, then i got a doppler and listened and it was indeed 225. the moms vs were stable her temp was 98.2. i turned her to her left side and after about a minute the fhr rate went back to 140's. called the dr to let him know. 5 min after that, it did it again, this time staying tachycardic for 1 3/4 hrs. called the dr, who told us to "quit waking him, what was he supposed to do the baby was just playing around" ran an iv of LR, o2 via facemask which the pt refused to keep on continually, changed her position from R to L to semi and back again, nothing seemed to help. Called the local tertiary care center to consult with a RN there who said she had never had such a thing either, suggested all the interventions i had already done. called our nsg supervisor who also had no new insights. I then called the MD and told him i was NOT comfortable with this, and i did NOT like it and i wanted him to come in RIGHT NOW.. he waffled a bit and then said he would transfer the pt to tertiary care hospital. Got everything ready to go and the darling 17yr old in all her wisdom REFUSED to go. while we were trying to change this childs mind had a US done(which took the tech 70 minutes to get in-she was on call) she came running out to us saying the fhr was in the 80's, she "WATCHED it drop, the baby had no movement and no fetal respirs... we turned pt to left side, MADE her put the 02 back on ,fhr was 140's and the tech proceeded with the BPP to which she gave an 8/8

i asked her HOW she could do that given the 'distress' she witnessed and she gave me some convoluted story and stuck with her 8/8

the dr called back in to see if she was gone, we told him she wanted to sign out AMA to go home to sleep, and he said he was coming in,. called the ped on call to let him know what was happening, he came in for the 'just in case' and the ob finally showed up 1.5 hrs later. when i LEFT this am the dr was considering sending her HOME and scheduling a fetal echo the following day at the tertiary care center. he decided daily nst's would be enough.

i havent called back in to see what REALLY did happen today BUT my QUESTION IS,.... have any of you encountered such prolonged fhr tachycardia and WHAT DID YOU DO?

THANKS for sticking with me in this saga! im anxious to hear your responses.

Thank you very much for sharing this experience with us. I am a new to OB field and have not encountered something like you described, not yet. But thanks to you and others, I know what to expect in the similar situation and will be prepared. :)

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Specializes in ob gyn.

:yeah:thanks to all for responding.

when i went back to work last night i found out she had signed herself out AMA in the am, shortly after our shift ended. she was told to go immediatly to the tertiary care center. she didnt go there until early evening. talked to the nightshift nurse last night who said the baby wasnt tachy then and they were planning to do a level 2 US and echo this am. i'm just glad when she got there they could find a heartbeat.

i havent slept the past two days for dreaming about this patient. AGHR! makes me NUTS as to how STUPID some people can be.

again. thanks for your advice and support

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Okay, so I'm curious. Did you call in to find out what they decided to do with her?

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Specializes in Med-surgical; telemetry; STROKE.
Thanks for sharing your experience :up:

Could it be Wolff-Parkinson White (WPW) Syndrome or some other type of SVT? I haven't seen anything like that on EFM (thankfully!) but we had a 12-hour old babe who on a vitals check had a heart rate in the 220-260s and had to be cardioverted (first tried the ice-bag to the face and then I think adenosine was what worked).

I remember reading somewhere that when fetal SVT is diagnosed in utero they often give meds (digoxin & other antiarrythmics) to mom to try and cardiovert before delivery. I think treatment often depends on the etiology, gestational age and severity (intermittent vs sustained) of the SVT. Sustained SVT can lead to congestive heart failure or hydrops, and can put the fetus at risk for demise.

Sounds like you did everything right to let the MD know that he needed to come in and assess the situation.:yeah:

I remember that something similar I saw in ER serial when to stop an arrhythmia a doctor in ER immersed the patient's face into a basin filled with cold water. Vasovagal response caused by rapid local hypothermia. Thank you for details!

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Specializes in ob gyn.

but the question is./ if its the baby in utero having the cardiac issue would dunking the moms face into the water do anything for it?

i am off for several days and wont be able to call the hospital where she is at. i'll talk to the md when i get back to work but who knows with him!

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Specializes in Med-surgical; telemetry; STROKE.
but the question is./ if its the baby in utero having the cardiac issue would dunking the moms face into the water do anything for it?

i am off for several days and wont be able to call the hospital where she is at. i'll talk to the md when i get back to work but who knows with him!

cold water or ice to the face will cause vagal response in the mother. I don't think that maternal vagal response can cause fetal vagal response.

This morning with hope to find more information about fetal SVT and interventions, I had searched online and found so many articles, but unfortunately, all of them were protected from a common reader.

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