1. Case Studies

2. 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

3. 04:15

4. 04:25-04:34

5. 5 AM Pitocin started

6. 05:20- 05:30

7. 05:35- 05:45

8. 05:46-05:56

9. 05:59- 06:09

10. 06:22- 06:32

11. 06:58-07:08

12. 07:56-08:06

13. 08:23-08:33
Patient reports painful contractions, requesting epidural

14. 08:52-09:02

15. 09:29-09:39

16. 09:39-09:49

17. 09:55-10:04

18. 10:10-10:20
Comfortable, feel some pressure. Cervix 4 cm/1 cm/0. IUPC placed.
Tracing?

19. 10:30-10:40

20. 11:12-11:22

21. 11:41-11:51
Maternal oxygen, Pitocin remains same rate

22. 11:55-12:04
Patient sleeping

23. 12:35-12:45

24. 13:00-13:10

25. 13:22-13:32

26. 13:33-13:42
Unable to find fetal heart tones. Cervix c/c/-1.Pitocin off. Uterine resting tone up to 40,tachysystole

27. 13:44-13:54

28. 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

29. 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

30. 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

31. Admission
Cervix: 1 cm/1 cm/-1

32. 22:36-22:46

33. 00:03-00:13

34. 00:36-00:46

35. 01:04-01:14
Patient is very uncomfortable, requests pain management

36. 01:25-01:35
Cervix: 6/80%/-2, bulging bag, head not engaged. Epidural

37. 01:45-01:55

38. 02:26-02:36
After epidural
FHT up BPM, gray area for alarm up to 170

39. 03:30-03:40

40. 4 AM:Bulging bag, ROM meconium, cervix: c/c/+1

41. 04:22-04:32

42. 04:35 AM. Pushing starts.

43. 04:46-04:56

44. 06:09-06:19
How often is she pushing? DO we have a baseline?

45. 05:37-05:47

46. 06:09-06:18
Maternal fever (101.3)-Amp/Gent. started

47. 06:41-06:51 Pushing for 2 hours. What is the baseline? Variability?
How is the tracing?

48. 06:55-07:05
Cervix: c/c/+1 with caput at +3

49. 07:14-07:24
Decision made for c section

50. 07:23-07:33

51. 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

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

53. 1000 CYTOTEC #1 Admission tracing 1000 Cytotec #1
Cervix closed long high
CYTOTEC #1

54. 1400
No cervical change Cytotec #2
CYTOTEC #2

55. 1800
Cytotec #3 no cervical change
CYTOTEC #3

56.
SROM at 2036
SVE= 5/75%/-1 at 2130
epidural
SROM
@ 2036

57.
SROM at 2036
SVE= 5/.5/-1 at 2130
epidural
SVE 5/.5/-1

58. 2229
FSE placed brady?
FSE placed

59. 2239
Notice gradual rise in baseline fetal heart rate from 2100 to end of tracing

60. 2305 8/C/O IUPC Amnio infusion started @2315 SVE 8/C/0 Teaching Point
Gradual raise in baseline from from end of tracing
Trends over time.
8/C/O

61. 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

62. 2350
9/C/0 no change
Rising baseline

63. 2356
Cervical check done cervix unchanged remains9/C/O

64. 0002
Note Contraction frequency

65. 0012
Frequency of contractions, not on Pitocin consider giving terbutaline
Cat II possible interventions
Variables or lates

66. 0022
To OR decision made to do C/S

67. 0029
Prolonged deceleration

68.
0037

69.
0037
Terminal brady

70. 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 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.

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

72. 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

73.
2/C/-2
Rechecked 2/C/-2

74.
SROM,clear
SROM clear

75.
Continuing tracing

76.
Continuing tracing

77.
Continuing tracing

81. con’t

83.
Epidural placement
6cm

85.
B/P 71/39
Drop in blood pressure following epidural placement

86.
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

87. 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

88. 1650-1655 IUPC placed 8-9/C/-1 IUPC placement
No change in cervical exam
8-9/C/-1

89.
Left side
oxygen
Oxygen on
Left side
Fetal scalp electrode

90.
Cervix un changed 8-9/C/+2

91. 1735
Continuing tracing

92.
Continuing tracing
Moderate variability /lates (?)

93.
T 37.6
Continuing tracing

94.
To right side
Prolonged deceleration

95.
to left
FSE
Repositioned to left
FSE
O2 remains on placed

96.
Continuing tracing
Raising baseline now there is enough of a tracing to get a baseline

97.
Continuing tracing
Note variability

98.
Continuing tracing
Recurrent variables

99.
C/C/+1
T 38.1
c/c/+1
TEMP 38.1

100.
LABORING DOWN
OP POSITITON

101.
Laboring down OP
Laboring down OP

102.
To Right
Position change recurrent lates, tachy

104.
BEGINING TO PUSH

106.
PUSHING

108.
Pushing started

109.
Continuing tracing
pushing

111. 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

112.
Pushing restarted
Deep variables
Prolonged decelerations

113. 2300
Continuing tracing

114. 2315
Continuing tracing

115. 2330
Continuing tracing
Raise in baseline fetal heart rate and raise in IUPC baseline

116. 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

117. 0000-0005 Vacuum applied on for five minutes with two pop off’s
IUPC out

118. 0010 Vacuum off Two pop offs +4 station
Vacuum off patient continues to push for another 18 minutes

119. 0020
Patient continued to push

120. 0028
Birth at 0028
delivery

121. 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,
Apgars 1,3,4
Suctioned, PPV, intubated
Newborn ABG 6.94, 62, 44, -22
Induced Hyperthermia Treatment for HIE
@ 12 months no neurologic deficits

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

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

124. 05:38-05:48
SROM, thick meconium

125. 06:06-06:16

126. 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

127. 06:30-06:40
Baseline is up? Causes of fetal tachychardia….

128. 06:39-06:49
Fever Ampicillin and gentamicin started

129. 06:55-07:05
tracing

130. 07:08-07:18
Fetal scalp, IUPC placed. Maternal oxygen, position to hands and knees

131. 07:15-07:25
Brisk vaginal bleeding. Cervical exam unchanged.

132. 07:28-07:38
OR tracing.

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

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

136. 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

137. 1939
T 39.1
Baseline fhr 170
Pitocin not started due to FHR and contraction pattern

138. 2037 Nursing documentation recorded as:
FHR baseline 170, moderate variability no acceleration and no decelerations.
Contractions regular every minutes, moderate intensity
Do you agree?
PCN G stopped and Amp/ Gent started for temp 39.1

139. 2119
4/C/-2
Requesting epidural at this time

140. 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

141. 2242
B/P 122/64

142. 2256
B/P 82/54

143. 2302
B/P 100/52

144. 2312 AROM forebag@2309 B/P 95/50 Cord compression
check for prolapsed cord
Reposition
B/P 95/50

145. 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

146. 2352
Continuation of tracing until 0006

147. 0006
Con’t tracing
Amnio infusion started

148. 0106
8/C/O OP
T 38.3

149. 0116
Continued tracing
Pay attention to the baseline. (170) Prolonged deceleration on next slide

150. 0122

151.
Base line
Variability
What type of decelerations

152.
Continued tracing

153.
C/C/+2 OA
T 38.0

156.
Practice pushing

158. 0238-0243 Pushing with every other contraction
Pushing with ever other contraction

159.
Continuing tracing
pushing

160.
Continuing tracing
pushing

161.
Continuing tracing

162.
Vacuum on

163.
Del
@ 0316

164. Outcome
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