The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. The nurse looks at me anxiously, waiting for instruction on what to do next. Glancing past her, I see she has all the supplies in the room to prepare for a cesarean section.
This is the patient’s* third pregnancy. The first two pregnancies culminated in beautiful 'Kodak moment' vaginal deliveries. However, this labor was not going quite as dictated by the birth plan...
Earlier that day, she had started her labor with a bradycardia, where the baby's heart rate had dropped to the 70's for several minutes. Luckily, it resolved nicely when we changed mom's position. The baby’s heart rate becam reassuring, showing signs of adequate oxygen and health. Her labor had progressed quite well until 8 cm at which point the baby’s heart rate tracing began to have late decelerations, which can be an indication of poor oxygenation. We rolled her onto her left side and applied oxygen, but despite our efforts, the decels worsened. With the next cervical exam, there was only a small amount of cervix remaining (“anterior lip”). The cervix is essentially like a very tight turtle neck that the baby's head has to squeeze through as it passes through the birth canal, with only the strength of the uterine contractions and gravity to help it escape. I placed her in 'knee- chest' position, hoping that gravity and physics might help dissolve the anterior lip of the cervix. I rechecked her and found that my attempts to convince her cervix to dilate were not working.
Time. How much time do I have to get this baby out? Assessing a baby during labor is like taking care of someone in the ICU with only one vital sign. No physical exam, no pulse OX, no stethoscope, just a 1 lead EKG to make your diagnosis. In obstetrics, we have only the fetal heart rate tracing and can infer limited information from it. There are a number of fetal heart rate patterns that can tell us the baby is healthy. Most of the “bad” patterns are not very accurate. Around 97%of the time even though the tracing looks “bad” the baby is still OK… but there’s no way to know for sure. Studies suggest that it takes up to 30 minutes of decreased oxygenation to lead to brain damage.
I look to my patient, knowing that she wants a vaginal delivery very strongly but she also has put her trust in me to help her have a safe delivery and a healthy child. I look at the clock, and see the pattern has been questionable for about 20 minutes. I need this baby out in 10 minutes or less.
Do I take her to the OR? Do I try to have her push?
If she pushes through the lip, I’m the hero for helping her achieving the much desired vaginal delivery. If it doesn’t work, we may have to rush the delivery and do a stat c-section.
I search the fetal heart rate tracing for one sign of reassurance. Come on give me something I can hang my hat on: an acceleration or some variability. I know the patient can do this vaginally if only we could buy her some time. The tracing, however gives me no reassurance.
Let’s try to push one time, I tell the patient. If you can’t bring the baby close enough to deliver were going back for a cesarean section.
The OR team begins to set up. I position her at the angle I think gives her the best shot at pushing past the anterior lip of the cervix.
With the push, the multiparous cervix dissolves and I feel the baby entering deeper into the birth canal.Yes, I think internally, this is going to work. As the contraction finishes, the head retreates back up into the pelvis and the cervix reappears. Crap.
The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. I meet the nurses anxious gaze. The art of obstetrics has failed me and now the science of it is pounding in my ear drum telling me that time is up. I have to call a stat section or the risk to harm to the baby will quickly climb above the risk of cesarean section to the mom.
The moment I call it, the room becomes well-oiled chaos. As we sprint to the OR, I wonder to myself if maybe we should have tried one more push? But on arrival to the OR the nurse rechecks the heart beat, finding it still in the 60s.
Moments later I pull a screaming healthy baby girl through a low transverse uterine incision. The cord had been wrapped tightly around the shoulders, preventing her descent. The baby comes out screaming, filling her lungs with much needed oxygen and quickly turning a healthy shade of pink. The mom cries gentle tears of relief.
Later in the waiting room, I let the family know mom and baby are fine.
I await their reaction.
The dad thanks me, with tears in his eyes.
These are the hardest calls to make. I had mere moments to decide the fate of this precious woman and her child. In this situation, the safest thing for the mother was a vaginal delivery whereas the safest thing for the baby was a cesarean section. I try my best to use the science available to balance the pendulum of mother's and baby's safety to achieve a healthy delivery for both. In the end, that's what matters most.
Photo credit to: www.amandamcnealphotography.com
*All patients examples are either used with the patient's permission or are a fictitious conglomerate of multiple patient encounters.
Also posted at ThePregnancyCompanion.com