Tuesday, January 26, 2010

CTG - Case study what would you do?

A gravida 2 para 1, 22 years old, uneventful pregnancy however in the last week developed high blood pressure: today not feeling well, visual disturbances and 1+protein in her urine, PE bloods taken, waiting results:
For Induction of Labour (IOL)@ 40 weeks.
Last baby spontaneous vaginal birth after an 8 hour labour, perineum intact.

admitted to ward at 1400hrs pre prostin CTG, normal reactive trace.

CTG recommenced post prostin 2mg @ 1600 hours..... describe the CTG and what action would you take...... what are your options and the womans options?


Anonymous said...

it would be interesting to know the Bishops Score?

Pam said...

immediately left lateral and facial O2. Call for help.

Begin to read the CTG by describing what is 'right' with it. This is obviously a consultation with obstetrician.
There is baseline variablity of between 5-10 beats and there are at least two accelarations that I can see.
Decelaration number three has some 'shouldering' as it is coming out of the decelaration suggestive of cord compression which comes from the venous release first as the contraction is ending and the babies circulating volume increases before pressure in the arteries of the cord are released and it can return to the baseline.
If the baby is small for dates then it will be using the resovoir of O2 in the retroplacental space due to the overstimulation. The uterine activity just from observing the trace is suggestive of possible overstimulation due to prostin. but I am aware I do not have a hand on her uterus to measure the contraction.
There needs to be an urgent VE and antitocolytic considered to alow time for the baby to recover from the event which appears to be prostin induced.If the uterine activity can be stopped then the baby with the active baseline and which is even reactive at the bottom of the decelarations has time to recover then the induction could be reconsidered hopefully trying an ARM in a multip.

The hypoxic baby will lose accelarations 1st, then reduce baseline variablity and then begin to compensate with a rising baseline. The problem comes as well when antihypertensives are used that reduce the variablity.

Otherwise my guess is the obstetrician would come in see the trace and do C/S.

As a midwife i need to recognise there are

InfoMidwife said...

Hi Pam, Thank you for your great response.
This is an interesting trace, I have the advantage as I was present....yes left lateral and call for help was the start.....the baseline is 150 bpm with persistant decelerations, the baby reacted to the prostin gell, the cervix was closed and there were no contractions....maternal pulse rate was 90bpm.... the client was turned left and right lateral, with no changes to the CTG.... we do not administer Oxygen unless there is maternal collapse due to the oxygen causing more harm to the fetus (due to free radicals). Yes I agree that there were some variable decelerations, however I felt that the variablity was still ok.
I have never seen such a marked reaction to prostin with no contractions present....an attempt to remove the prostin was made and as the trace did not improve the woman went for a c/s. I have seen this happen when the uterus is overstimulated (contractions)but not like this. The outcome was very good, baby apgars were 8 & 9 and the cord gasses were within normal limits.... so no adverse outcome, possibly as the obstetrician made the decision early. It is important to say that it is very hard to get clinicans to agree on a CTG interpretation... especially when it comes to some types of decelerations....early, late and complicated variable....

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