From the Editor
Transfer to the hospital for women planning a home birth: A high-risk obstetrics problem
Do you have a written clinical guideline for pregnant women planning a home birth who are transferred to your hospital?
CASE 3 Continued
The patient continues pushing for another 20 minutes without delivery, and the nurse raises a concern about the FHR tracing to the physician, who remains in the room but does not respond (FIGURE 5).
| FIGURE 5 FHR tracing reveals ongoing repetitive variable decelerations | ||
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This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers. | ||
TIP #5: Acknowledge and respond to other caregivers' concerns
A team approach to patient care is essential in all areas of medicine, perhaps none more so than in obstetrics. Each member of the team is engaged in trying to provide optimal patient care and the concerns of every team member--regardless of title or level of training--must be acknowledged and addressed. Good communication requires creating a safe environment wherein each member of the team feels comfortable raising concerns without fear of reprisal. Rather than becoming angry or frustrated when questioned, providers should remain cognizant that these are ongoing efforts to maintain situational awareness and ensure the best possible outcome for mother and baby.
CASE 3 Continued
Pushing continues for another 30 minutes despite the nurse's repeated effort to express concern to the physician about the FHR tracing. After more than 2 hours of pushing, the infant is delivered; Apgar scores are 1, 5, and 7. No cord gas is obtained.
TIP #4: Initiate the chain of command when necessary
Any caregiver, regardless of job title, has a duty to initiate the institution's chain-of-command policy and procedure if he or she has a concern about patient well-being that is not being addressed adequately. It can be uncomfortable for a nurse, midwife, or resident physician to question an attending physician, particularly if that person responds in a dismissive, condescending, or angry manner. If a caregiver has made several attempts to engage the attending physician and feels the concerns are being inadequately addressed, then he or she must respectfully initiate the chain of command to seek additional objective review of the clinical situation.
Failure to follow oxytocin protocols, inadequate surveillance, poor documentation
CASE 4 Induction of an uncomplicated pregnancy due to postdates
A 20-year-old woman (G1P0) at 42 weeks' gestation with an otherwise uncomplicated first pregnancy presents for postdates induction with oxytocin. After 6 hours, she develops uterine tachysystole with recurrent variable decelerations but the oxytocin infusion is continued at the same rate (FIGURE 6).
| FIGURE 6 FHR tracing indicates uterine tachysystole | ||
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The patient in Case 4 received oxytocin for induction of postdates pregnancy. The red arrow shown on the FHR tracing points out that oxytocin augmentation continues despite the presence of uterine contractions that are too frequent and initial changes, including subtle late decelerations in the FHR, that suggest early fetal compromise. | ||
TIP #3: Manage oxytocin infusion according to protocol
Inappropriate use of oxytocin is common, including the improper management of oxytocin infusion in the setting of uterine tachysystole (defined as the presence of >5 contractions over a 10-minute period averaged over 30 minutes) and/or an abnormal FHR tracing. The mismanagement of uterine tachysystole is cited in more than two-thirds of obstetric malpractice cases.12
Uterine contractions alter blood flow through the spiral arteries and transiently reduce placental perfusion. Prolonged uterine tachysystole can lead to fetal oxygen debt and early signs of hypoxia, including the loss of spontaneous accelerations, tachycardia, and reduced variability. Continuing or increasing the oxytocin in the setting of such changes is hard to justify. One study found that the use of oxytocin in the setting of tachysystole was significantly associated with signs of fetal asphyxia (odds ratio [OR], 5.6).13 When the FHR pattern suggests significant interruption of fetal oxygen delivery and possible hypoxia, continuing or increasing an oxytocin infusion suggests a lack of understanding of the physiology that is the basis for FHR interpretation.
Appropriate management of tachysystole depends on the accompanying FHR.14 In the setting of a category I (normal) FHR tracing, tachysystole can be treated first with maternal repositioning (left or right lateral) and administration of a 500-cm3 maternal IV fluid bolus. If uterine activity does not return to normal after 10 to 15 minutes, decrease the oxytocin rate by at least half. If it does not return to normal after another 10 to 15 minutes, discontinue oxytocin until the tachysystole has resolved.
In the setting of a concerning category IIFHR tracing, discontinuation of oxytocin should be the first step along with maternal repositioning and administration of a fluid bolus. If these measures do not improve the FHR tracing and tachysystole persists, administration of an acute uterine relaxant, such as terbutaline, should be considered to slow contraction frequency.
