one practicum question

CEG · Oct 24, 2009

Hi im doing my focus practicum in maternity
yesterday i had a pt who had a planned birth but was transferred to our hospital due to the failure of progress of 1st stage of labor. She was 7cm around 8pm, then 8cm around 10pm, baby OT, until 12pm she was still 8cm, baby OA(good thing), then FHM was all good, baseline 140ish, suddenly came up with 2 big decel lasted 2minutes each. So the doctor said doing a section for her
i read about the aminoinfusion which could release cord compression. Doctor suspected cord compression which caused decel, but we were hoping she could progress to 10cm cuz baby is OA so she can push.
My logic is why dont we give aminoinfusion for her to see whether she can be 10cm so she can push instead of a csecion?
i know aminoinfusion is used to dilute meconium and also release cord compression. i asked around they said it is because she failed to progress in 2hours, oh btw, she had epidural....
another thing is her urine is really orange colour, either dehydrated or mixed with blood, maybe infection as well because she suddenly developed a fever from 37.8 during 2 big decel -39.2 during csection. Doctor said probably it is corioaminotitis....Im just curious about her urine, what can i do about that? it is definately not foley, i put the foley in by one shot, took me 5minutes, all sterile.
idont know, i felt like if im the doctor i would totally make the wrong judgement, doctor said they never use aminoinfusion, so.....any clearify on that?
millions thx

With amnioinfusion, it is not recommended for meconium any more. It does not decrease incidence of meconium aspiration syndrome. It can improve cord compression and is actually linked with reduced rates of chorioamnionitis. Not sure if the doc meant they never use it for mec or they never use it at all.

I have seen the urine get orangish like that. In the absence of other problems (oliguria) we have attributed it to bladder trauma due to pressure of the baby's head.

As for the section, the biggest indicator of fetal well-being is variability. So two "big" (remember that they are not prolonged decels until they are > 2 minutes) with moderate variability is much less concerning than two decels with minimal variability. You have to look at the whole strip, not just the presence of variables.

Failure to make progress in two hours is not really based on a standard. Current guidelines are to asses progress for three hours before intervening if the patient falls off a labor curve. Friedman's curve has essentially been shown to be not evidence-based. Chorioamnionitis causes ineffective contractions and if the doctor was truly thinking chorio then he probably figured there was no value in continuing.

Assuming heart tones were not too awful I as a provider would have inserted an IUPC to see if the contractions were adequate, considered augmentation depending on the results, if repositioning the patient was ineffective considered starting amnioinfusion to relieve cord compression, and started antiobiotics for suspected chorio (keeping in mind that epidurals cause temperatures as well so chorio may not be a factor). As a CNM though I obviously try to avoid section.

This doc may have consciously or unconsciously moved to section quickly because she was a homebirth transfer for a variety of reasons- to "punish" her for attempting a homebirth, fear of liability after a homebirth transfer, laziness and desire to get home quickly after a patient was "dumped" on him, or true concern for the safety of the baby/mom. It's tough to say.

whitebunny · Oct 24, 2009

Thank you so much for clearfying everything for me!

Honestly, I am student so pretty much that doctor doesnt give a damn about me, my perceptor cut me off as well they simply said they just never did an aminoinfusion ever.

I really doubt this doctor's decision, but thank you for clearfying the amnioinfusion and FHM for me. That gives me confidence I wasnt really on the wrong track. BTW, i should tell you that baby has cord wrapped around his neck----i think this is important info im sry i didnt tell you earlier, that could explained Csection overall. But yes you are right, that doctor is in a rush.

CEG · Oct 24, 2009

It may very well have been that the baby could not descend due to a tight cord of that the wrapping of the cord was causing the variables and would have gotten worse.

About 25% of deliveries have nuchal cords and typically there is no issue.

whitebunny · Oct 24, 2009

It may very well have been that the baby could not descend due to a tight cord of that the wrapping of the cord was causing the variables and would have gotten worse.
About 25% of deliveries have nuchal cords and typically there is no issue.

ok, because of the nuchal cords that baby cannot descend and having variabilities. so 3/4 babies still would have issues right? so doctor's csection is still a correct judgement. There is almost no possibility for aminoinfusion?

CEG · Oct 24, 2009

ok, because of the nuchal cords that baby cannot descend and having variabilities. so 3/4 babies still would have issues right? so doctor's csection is still a correct judgement. There is almost no possibility for aminoinfusion?

Sorry, I meant that 25% of all deliveries have nuchal cords and with most of the 25% there are no issues.

It's possible that the nuchal cord was causing the decels and the slow dilation but there's no way of knowing since most of the time nuchal cords cause no issue. Hope that's a little clearer.

If the decels were caused by the cord and it was preventing baby from descending then I wouldn't think amnioinfusion would be helpful. Of course we don't really non any of this, we are just guessing...

Also- "variability" is the way the baby's heart rate goes up and down over time. "Variables" are the decelerations of the heart rate. Variability is a good thing, we want to see moderate variability. Variables can be cause for concern.

whitebunny · Oct 24, 2009

Sorry, I meant that 25% of all deliveries have nuchal cords and with most of the 25% there are no issues.
It's possible that the nuchal cord was causing the decels and the slow dilation but there's no way of knowing since most of the time nuchal cords cause no issue. Hope that's a little clearer.
If the decels were caused by the cord and it was preventing baby from descending then I wouldn't think amnioinfusion would be helpful. Of course we don't really non any of this, we are just guessing...
Also- "variability" is the way the baby's heart rate goes up and down over time. "Variables" are the decelerations of the heart rate. Variability is a good thing, we want to see moderate variability. Variables can be cause for concern.

thank you very much! now it clears very much of my confusion!