Case Studies

Case: 34 years old female G4 P3 at 39 6/7 weeks. Admitted with SROM 4 hours prior to admission. Unremarkable prenatal care. OB history: Previous vaginal deliveries at term. GBS negative. Patient speaks only Spanish Does not report contractions Cervix: 2-3 cm/1.5 cm/-2/cephalic

04:15

04:25-04:34

5 AM Pitocin started

05:20- 05:30

05:35- 05:45

05:46-05:56

05:59- 06:09

06:22- 06:32

06:58-07:08

07:56-08:06

08:23-08:33 Patient reports painful contractions, requesting epidural

08:52-09:02

09:29-09:39

09:39-09:49

09:55-10:04

10:10-10:20 Comfortable, feel some pressure. Cervix 4 cm/1 cm/0. IUPC placed. Tracing?

10:30-10:40

11:12-11:22

11:41-11:51 Maternal oxygen, Pitocin remains same rate

11:55-12:04 Patient sleeping

12:35-12:45

13:00-13:10

13:22-13:32

13:33-13:42 Unable to find fetal heart tones. Cervix c/c/-1.Pitocin off. Uterine resting tone up to 40,tachysystole

13:44-13:54

Outcome Patient takng to the OR for emergent c section Delivery of a 3440 grams baby with Apgars of 1 and 5 Arterial pH 6.9 Venous cord pH6.97 Uterine rupture: left side anterior uterine wall going down 8 cm into the vagina

Uterine Rupture Increased suspicion for uterine rupture; Bradycardia preceding or accompanied by recurrent late decelerations Uterine tachysystole Change in pattern Severe pain Location/quality Vaginal bleeding To use with strip of uterine rupture

Case: 33 years old G2 P1 39 4/7 weeks. Hx of LEEP and previous LTCS for breech. Membranes are intact. Admitted in early labor. GBS negative

Admission Cervix: 1 cm/1 cm/-1

22:36-22:46

00:03-00:13

00:36-00:46

01:04-01:14 Patient is very uncomfortable, requests pain management

01:25-01:35 Cervix: 6/80%/-2, bulging bag, head not engaged. Epidural

01:45-01:55

02:26-02:36 After epidural FHT up 10-20 BPM, gray area for alarm up to 170

03:30-03:40

4 AM:Bulging bag, ROM meconium, cervix: c/c/+1

04:22-04:32

04:35 AM. Pushing starts.

04:46-04:56

06:09-06:19 How often is she pushing? DO we have a baseline?

05:37-05:47

06:09-06:18 Maternal fever (101.3)-Amp/Gent. started

06:41-06:51 Pushing for 2 hours. What is the baseline? Variability? How is the tracing?

06:55-07:05 Cervix: c/c/+1 with caput at +3

07:14-07:24 Decision made for c section

07:23-07:33

Delivery by c section Apgars 2 and 7 Mec below the cords Blood gases: -Arterial ph 6.91 Base excess -20 -Venous ph 6.95 Base excess not done Weight 3.4 kg No cooling as gases improved by 1 hour and no signs of HIE

Case 30 y.o. G1P0 41 weeks Induction for post dates Cervix 1/long/high

1000 CYTOTEC #1 Admission tracing 1000 Cytotec #1 Cervix closed long high CYTOTEC #1

1400 No cervical change Cytotec #2 CYTOTEC #2

1800 Cytotec #3 no cervical change CYTOTEC #3

2115-2130 SROM at 2036 SVE= 5/75%/-1 at 2130 epidural SROM @ 2036

2115-2130 SROM at 2036 SVE= 5/.5/-1 at 2130 epidural SVE 5/.5/-1

2229 FSE placed brady? FSE placed

2239 Notice gradual rise in baseline fetal heart rate from 2100 to end of tracing

2305 8/C/O IUPC Amnio infusion started @2315 SVE 8/C/0 Teaching Point Gradual raise in baseline from 130-170 from 2100- end of tracing Trends over time. 8/C/O

2328 9/C/O 9/C/0 Teaching Point: Contractions every minute give terbutaline Notice gradual rise in baseline fetal heart rate from 2100 to end of tracing

2350 9/C/0 no change Rising baseline

2356 Cervical check done cervix unchanged remains9/C/O

0002 Note Contraction frequency

0012 Frequency of contractions, not on Pitocin consider giving terbutaline Cat II possible interventions Variables or lates

0022 To OR decision made to do C/S

0029 Prolonged deceleration

0035-0039 0037

0037-0043 0037 Terminal brady

OUTCOME Male born at 0046 via C/S 3 vessel cord/body cord 4141 GM Apgars 2,9 Cord gases A- 6.97, 95, 5, -17 V- 6.99, 81, 13, -17 Last tracing at 0043--- importance if FSE Male born at 0046 via C/S 3 vessel cord/body cord 4141 gm Apgars 2,9 Cord gases A- 6.97, 95, 5, -17 V- 6.99, 81, 13, -17 Babe to transition nursery for respiratory distress resolved in 30 minutes transferred to normal newborn nursery.

Case G1Po 40 3/7 weeks GBS positive ( in urine) G1P0 403/7 GBS + Spontaneous labor

Admission 0730 1/C/-3 This is the admission tracing Patient in triage to r/o labor 1/C/-3 Will recheck in two hours

1034-1041 2/C/-2 Rechecked 2/C/-2

1047-1054 SROM,clear SROM clear

1107-1113 Continuing tracing

1118-1124 Continuing tracing

1139-1147 Continuing tracing

1400-1405

1403-1410

1433-1448

1433-1448 con’t

1446-1452

1459-1505 Epidural placement 6cm

1505-1511

1510-1516 B/P 71/39 Drop in blood pressure following epidural placement

1516-1522 6/.5/-1 6cm b/p 89/51 B/P remains in this range for the next hour and the tracing looks the same Anes notified

1618-1624 8-9/C/-1 Oxygen on B/P 121/58 Blood pressure 121/58 O2 on now until end of tracing Oxygen on B/P 121/58

1650-1655 IUPC placed 8-9/C/-1 IUPC placement No change in cervical exam 8-9/C/-1

1656-1703 Left side oxygen Oxygen on Left side Fetal scalp electrode

1704-1711 Cervix un changed 8-9/C/+2

1735 Continuing tracing

1743-1748 Continuing tracing Moderate variability /lates (?)

1751-1757 T 37.6 Continuing tracing

1757-1802 To right side Prolonged deceleration

1801-1807 to left FSE Repositioned to left FSE O2 remains on placed

1807-1813 Continuing tracing Raising baseline now there is enough of a tracing to get a baseline

1820-1825 Continuing tracing Note variability

1830-1835 Continuing tracing Recurrent variables

1906-1913 C/C/+1 T 38.1 c/c/+1 TEMP 38.1

1932-1937 LABORING DOWN OP POSITITON

1939-1945 Laboring down OP Laboring down OP

1946-1952 To Right Position change recurrent lates, tachy

2002-2008

2029-2034 BEGINING TO PUSH

2035-2041

2051-2057 PUSHING

2102-2108

2134-2140 Pushing started

2140-2145 Continuing tracing pushing

2146-2152

2213-2220 BRIEF BREAK FROM PUSHING PUSHING FOR TWO HOURS HEAD ASYNCLITIC ultra sound showed fetal head transverse Discussed with patient that OVD was not an option discussed C/S Patient refused will keep pushing

2236-2243 Pushing restarted Deep variables Prolonged decelerations

2300 Continuing tracing

2315 Continuing tracing

2330 Continuing tracing Raise in baseline fetal heart rate and raise in IUPC baseline

2350 From OP to OA Good maternal pushing effort Decision made to do OVD based on maternal fatigue, maternal fever, meconium and reccurent variable decelerations. Temp 38.2 @2300

0000-0005 Vacuum applied on for five minutes with two pop off’s IUPC out

0010 Vacuum off Two pop offs +4 station Vacuum off patient continues to push for another 18 minutes

0020 Patient continued to push

0028 Birth at 0028 delivery

Outcome VAVD Male, 3082grams UA 7.06,71,17, -12 UV 7.13, 59, 23 -11 Apgars 1,3,4 Suctioned, PPV, intubated Newborn ABG 6.94, 62, 44, -22 Induced Hypothermia Treatment for HIE @ 12 months no neurologic deficits VAVD Male, 3082grams UA 7.06,71,17, -12 UV 7.13, 59, 23 -11 Apgars 1,3,4 Suctioned, PPV, intubated Newborn ABG 6.94, 62, 44, -22 Induced Hyperthermia Treatment for HIE @ 12 months no neurologic deficits

Case: 35 years old G 1 P0 39 weeks. Admitted in early labor GBS positive Prenatal care uneventful

Admission Cervix: 3 cm/70%/-3. Membranes intact

05:38-05:48 SROM, thick meconium

06:06-06:16

06:20-06:30 Patient very uncomfortable. Cervix:7cm/0.5 cm/-2. Anesthesia to place epidural. Tracing: Baseline 160, variability minimal to moderate, late appearing decelerations

06:30-06:40 Baseline is up? Causes of fetal tachychardia….

06:39-06:49 Fever 102.2. Ampicillin and gentamicin started

06:55-07:05 tracing

07:08-07:18 Fetal scalp, IUPC placed. Maternal oxygen, position to hands and knees

07:15-07:25 Brisk vaginal bleeding. Cervical exam unchanged.

07:28-07:38 OR tracing.

Outcome -Delivery by c-section. -Female, weight 3219 gm -Apgars 2 and 9 -Arterial pH 7.23 and Venous pH 7.28

Case G1 P0 39.6 weeks SROM @ 0800 arrived at hospital @1640 SVE 1/1/-3 GBS positive G1p0 39.6 SROM @ 0800 arrived at hospital @1640 SVE 1/1/-3

Admission T 36.9, HR-98 R 16 B/P 122/77 This is the admission tracing. Patient states that she ruptured her membranes at 0800 this morning and has having contractions every 5 minutes. She reports some small spotting and notes fetal movement. The plan is to start ATB (PCN G )because she is GBS positive and Pitocin augmentation because she is 1/1/-3 after being ruptured for 8 hours. Baseline 150 moderate variability

1939 T 39.1 Baseline fhr 170 Pitocin not started due to FHR and contraction pattern

2037 Nursing documentation recorded as: FHR baseline 170, moderate variability no acceleration and no decelerations. Contractions regular every 1.5-2 minutes, moderate intensity Do you agree? PCN G stopped and Amp/ Gent started for temp 39.1

2119 4/C/-2 Requesting epidural at this time

2226 Spinal dose B/P 122/63 Spontaneous tachysystole Interventions Reposition IV fluid bolus remember she is febrile and laboring will need extra fluid left shift in the oxygen dissociation curve Spinal dose B/P 122/63

2242 B/P 122/64

2256 B/P 82/54

2302 B/P 100/52

2312 AROM forebag@2309 B/P 95/50 Cord compression check for prolapsed cord Reposition B/P 95/50

2322 B/P 119/65 R lateral tilt FHR 180 variables Plan to continue to monitor and place an IUPC for amnioinfusion if variables don’t go away

2352 Continuation of tracing until 0006

0006 Con’t tracing Amnio infusion started

0106 8/C/O OP T 38.3

0116 Continued tracing Pay attention to the baseline. (170) Prolonged deceleration on next slide

0122

0126-0132 Base line Variability What type of decelerations

0134-0139 Continued tracing

0202-0209 C/C/+2 OA T 38.0

0210-0217

0218-0223

0225-0230 Practice pushing

0231-0236

0238-0243 Pushing with every other contraction Pushing with ever other contraction

0246-0251 Continuing tracing pushing

0252-0257 Continuing tracing pushing

0259-0304 Continuing tracing

0305-0310 Vacuum on

0309-0316 Del @ 0316

Outcome VAVD @ 0316 Male 2.91 kg Apgars 3,7 to NICU for observation for sepsis Cord art. 7.03,81,6,-14 Cord ven. 7.05,76,16,-13