Giving birth is supposed to be a joyous occasion, marked by cigars, balloons and well wishes. What if your birth does not go as planned. If your baby comes out with low Apgar scores, an ominous sign or, develops signs of Cerebral Palsy or hypoxic brain injury.
Fetal Heart Rate Monitors
Fetal heart rate monitoring is used almost universally in the United States. It is a window as to how your baby is tolerating labor. It is a sign of overall Maternal-Fetal Health.
Despite the importance of fetal heart rate monitoring, standardized adoption of its use to monitor fetal distress was only established in 2008 by the American Academy of Obstetrics and Gynecology and Society for Maternal Fetal Medicine.
And even as “guidelines” the promptness to which these guidelines are followed by hospital nursing staff and Obstetrician’s is still not uniformly followed due to any number of reasons, from nursing not reporting what are termed “late decelerations,” signs that the fetus is in trouble, promptly or with any algorithmic procedure. Even when appropriate nursing interventions are followed, how long have these late decelerations been allowed to go on? When was the doctor notified? How long did it take him or her to act on this ominous sign? The literature shows too long. Emergent delivery, typically via cesarean section, should take place within 30 minutes, and this simply does not happen.
Most expectant mothers place their faith in the hospital staff to take good care of them when they go into deliver. They strap the fetal heart monitor across your belly, you may or may not have an epidural, you get intravenous fluids, your vital signs are monitored as well as the babies. You may or may not receive medications or procedures to move your labor along. All is right? Yes?
Unfortunately, these measures do not indicate the person administering them and interpreting them to be competent to do so. Maybe nurses are distracted, have multiple patients. Maybe doctors are too optimistic that these aberrations in fetal heart rate, late decelerations, will clear with conservative measures. Maybe they are delivering Mrs. Jones down the hall, or driving in from home.
Time is critical when your fetal heart tracing shows late decelerations. Maybe you have never heard the term. A late deceleration is the time it takes for the baby’s heat rate to return to normal after a contraction. The baby’s heart must distribute blood to all the body, and the brain is particularly sensitive. The tracing looks like an EKG tracing, because that is what it is. Other methods for measuring fetal distress such as fetal auscultation are proven to be effective but not used due to 1) nursing staff not adequately trained in their use and 2) It would “create a financial burden to the hospital”.
Causes of “late decelerations” or the drop in heart rate with uterine contraction are known to be : uteroplacental insuffiency ( not enough oxygen to the baby), amniotic fluid infection which can occur due to excessively long labor is permitted after the water has been broken, low maternal blood pressure, complications of spinal or epidural anesthesia, uterine hyperactivity (often caused by the excessive use of Oxytocin) and large babies ( which are arguably even candidates for a vaginal delivery)and placenta previa or abruption in which the placenta has become displaced from the uterine wall, damaged and not effectively giving the baby the oxygen it requires.
The American College of Gynecology Guidelines of 2014 terminology defines a late deceleration as:
- A visually apparent symmetrical gradual decrease in return to fetal heart rate, associated with uterine contraction.
- The decrease in fetal heart rate calculated from onset of contraction to nadir (lowest point) to be equal or greater than 30 seconds.
- A deceleration is delayed in timing with the nadir occurring after a peak contraction
- In most cases, the onset, nadir and recovery of decelerations occur after beginning, peak and ending of uterine contraction.
- Further, they determine the cause to be “uteroplacental insuffiency” which is a fancy term that means the baby is not getting enough oxygen.
The brain is highly sensitive to even small amounts of decreased oxygen. As little as 3 minutes is linked to brain damage, and can cause cerebral palsy, which is due to brain damage from decreased oxygen. This may present as low “Apgar Scores” which all babies are rated on upon delivery. Studies have shown cortical and midbrain damage due to uteroplacental insuffiency. Is your baby making all of his/her developmental milestones promptly?
When late decelerations appear, prompt intervention is required. Nursing interventions, when the nurse recognizes them, is highly individualized, and how long she allows them to persist is also highly individualized. Nursing interventions include, turning the mother, increasing the IV fluid rate, providing supplemental oxygen at a rate of 8 Liters/minute, turning of Oxytocin medication and notifying the Obstetrician as soon as possible. The Obstetrician may elect “watchful waiting” or may place a fetal scalp monitor to measure blood acidity level, an indicator of low oxygen.
Recurrent late decelerations and recurrent variable decelerations, and fetal bradycardia, as well as low fetal scalp pH are indications for prompt action, such as an emergency cesarean section, if an instrumental delivery (with its own antecedent risks) cannot be performed immediately. When a fetal scalp monitor readings are low (especially below 7.20) the fetus is in serious trouble and needs to be delivered within 30 minutes. Sadly, this is rarely the case.
If you have had a baby who has had “low Apgar scores”, has had developmental delays or was diagnosed with cerebral palsy or hypoxic brain injury, you should know the emotional and financial toll that will last a lifetime. Contact the top-rated and experienced birth injury lawyers at Passen & Powell for a free consultation by calling 312-527-4500.