help me figure out what went wrong with this pt's labor!

[adpiRN]

My pt last night was pretty straightforward - 29, first baby, no medical problems. A little elevated BP on admission (130s-140s/80s-90s) which I guess was new because it wasn't picked up on a few days before at her OB's office.

She broke her water at 40 weeks and went into her own labor, no pitocin needed.

The tracing was basically fine, just 1late decel.

Then after she got her epidural it got BAD. Prolonged decels down to the 60s. Deep, long variables. We repositioned, gave her 02, I put in her foley, opened fluids wide. Nothing seemed to help. Her BP was down a little from the epidural, but not much (I think 120s-130s/60-80s).

After 20 minutes of this we did a c-section. I was the baby nurse in the OR and 2 things I noticed were the baby had a very thin cord. Maybe more easily compressed? Or a cause of not enough perfusion?

The baby also had peeling skin on its feet. Maybe the due date was wrong and the baby was more like 41 or 42 weeks?

Or for whatever reason the placenta was just not working as well anymore?

Do you think there would have been the same outcome if she hadn't had an epidural?

What if she'd been in a birthing center without continuous fetal monitoring? Would the baby have come out fine if no one had noticed these decels? Or could that have been a disasterous situation that could have resulted in damage or death to the baby if she had been allowed to labor for a few more hours (she was only 3cm btw) without anyone being aware of these decels?

[HeartsOpenWide, RN]

That does not sound like enough of a B/P change to cause a problem although with an old placenta I could see a drop in B/P being more significant than on a non post-dates baby. Reasearch has not show that continuous fetal monitoring to be an more safter than intermittent. Its just a lot easier on the nurse than intermittent.

[SmilingBluEyes]

A small drop in BP complicated by a marginally-perfused fetus (Postmaturity/placental issues, low AFI?) and cord compression CAN cause a baby to decompensate.I would love to have reviewed the strip to and know: Were cord gases done? This would present a more clear clinical picture for me. And while the research shows Continuous EFM is not necessarily helpful or improves outcomes in Low risk situations, it sure as heck is warranted in the presence of regional anesthesia, (which elevates the situation to higher risk)----as evidenced by this case. Again, what were the cord gas readings? Was the placenta examined by pathology? Honestly, that will complete the picture more.

[NewNurseyGirl2009]

How much fluids did she have prior to epidural? And were they within an hour before it was given?

[NurseNora, BSN, RN]

When the BP drops, one of the body's compensatory mechanisms if to vasoconstrict all the unnecessary organs. Unfortunately for us, the uterus is not considered necessary to the body. This mechanism can keep the mom's BP from showing a drop while compromising placental perfusion enough to cause fetal distress. Especially in an old placenta. Where there infarcts or lots of calcification?

A thin cord is more easily compressed than the usual fat one full of Wharton's jelly. Had she made rapid progress after the epidural?

Do your anesthesia people use Ephedrine for BP problems? The reason OB is the only department that still uses Ephedrine instead of one of the modern drugs to raise BP is that for some reason, Ep[hedrine doesn't cause vasoconstriction in the uterine arteries.

Things would have probably worked out well in a birthing center, because she wouldn't have gotten an epidural. The timing of the decelerations makes it seem it was probably related to the epidural. If it was due to the wimpy cord or an aging placenta, a problem would have been picked up and the patient transported to a hospital where a C/S could be done.

Auscultation is an acceptable method of monitoring. Just because a woman isn't hooked up to a machine, doesn't mean she isn't being monitored. I started working in L&D before there were fetal monitors and we didn't lose more low risk babies than we do now.

[babyktchr, BSN, RN]

I would like to know what the variability was in the strip much more than the late decel. With her pressures being increased, the drop probably did cause issues with the perfusion of the placenta. A post date baby (it sounds like it was) has a compromised oxygenation status from the beginning and labor just hacks at that oxygenation. Sounds like your baby just didn't have reserves left to compensate for labor and the decreased perfusion to the placenta. Tired baby and placenta.

You have to be gentle with these already fragile babies. IUGR, post dates, chronic hypertensive moms, smokers....they all have compromised oxygenation even before labor because of placental issues (calcification, smaller surface area, etc). If have aggressive labor or tachysystole, the baby just doesn't have it to bounce back after all of the assaults on its oxygenation. Most likely you get a dish rag baby when it comes out.

[CEG]

When the BP drops, one of the body's compensatory mechanisms if to vasoconstrict all the unnecessary organs. Unfortunately for us, the uterus is not considered necessary to the body. This mechanism can keep the mom's BP from showing a drop while compromising placental perfusion enough to cause fetal distress. Especially in an old placenta. Where there infarcts or lots of calcification?

A thin cord is more easily compressed than the usual fat one full of Wharton's jelly. Had she made rapid progress after the epidural?

Do your anesthesia people use Ephedrine for BP problems? The reason OB is the only department that still uses Ephedrine instead of one of the modern drugs to raise BP is that for some reason, Ep[hedrine doesn't cause vasoconstriction in the uterine arteries.

Things would have probably worked out well in a birthing center, because she wouldn't have gotten an epidural. The timing of the decelerations makes it seem it was probably related to the epidural. If it was due to the wimpy cord or an aging placenta, a problem would have been picked up and the patient transported to a hospital where a C/S could be done.

Auscultation is an acceptable method of monitoring. Just because a woman isn't hooked up to a machine, doesn't mean she isn't being monitored. I started working in L&D before there were fetal monitors and we didn't lose more low risk babies than we do now.

All of this!!! Birth centers do monitor the baby, they do intermittent auscultation which is just as effective as continuous monitoring with a lower morbidity rate (fewer unnecesary c-sections). It seems that what "went wrong" in this mom's labor was the epidural. Even though they are incredibly common they are an intervention that carries risk.

Birth centers do not put additional risks on mom and baby like many of our hospital interventions do. Your patient is a prime example- mom and baby are fine but suffered higher morbidity in the hospital.

[PegRNBSN]

I don't think you can say with certainty that mother and baby were fine. I would like to know if preeclamptic labs were done. While the epidural may have been the factor that precipitated the fetal distress, you don't know what would have happended with advancing labor without the epidural.

I too would like to see cord gases.

[SmilingBluEyes]

Agree with Peg here. Birth center protocols and those in the hospital are different for good reasons.