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.
Interesting case!!! I'm curious to know what became of mom and baby and sounds like the baby had an arrythmia. I just had this happen to me a few weeks ago. We knew the baby had an arrythmia and she came up to our unit from the perinatal center to be induced. Baby looked fine for about 30 minutes then converted to arrythmia and fhr was in 70's. I told OB there was no way we could induce her. He did C/S baby came out fine and converted at birth.
I have had an experience similar with the tachycardia but without the rapid deceleration. For the tachycardia, our docs may treat with digoxin for mom (after consultation with peds cardiology). Some of the physiology was explained to me after witnessing tachycardia. There are potentially 2 causes. One being electrical or it can be because the flap from the foramen ovale flips up into the atria causing irritation and the tachycardia. Similar to when something in the adult ventricle will cause ventricular tachycardia. However, a definitive cause is usually not identifiable until after birth. If it is caused by mechanical (foramen ovale) birth will eliminate the issue because of the changing pressure gradients associated with the change from fetal circulation to independant circulation. If it is electrical, the tachycardia will continue post delivery and cardiology will treat and manage based on the assessment after delivery.
Depending on the duration of the deceleration, I would say that it almost needs to be looked at seperately than the tachycardia. It may have absolutely nothing to do with it. I would think interventions and treatment would be based on whatever you would do in any other case of FHR in 80s.
Wow, sounds like it was pretty impressive and stressful. I don't have much OB experience but I had a pt one night where the FHR was making these huge arcs. Baseline 170s and then would arc and drop to 110 and back up again, very strange. Baby got tachy too up to the 220s prior to the arcs forming. Stressed me out for hours. I bugged the OB so much he finally came in, looked at the strip and then went home. Go figure.
ldcmw1
35 Posts
Interesting case!!! I'm curious to know what became of mom and baby and sounds like the baby had an arrythmia. I just had this happen to me a few weeks ago. We knew the baby had an arrythmia and she came up to our unit from the perinatal center to be induced. Baby looked fine for about 30 minutes then converted to arrythmia and fhr was in 70's. I told OB there was no way we could induce her. He did C/S baby came out fine and converted at birth.