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OB: What is a late deceleration? (case and discussion--long)From: Garry Siegel (garrys@mindspring.com)Mon Nov 27 20:09:32 2000
Here's a issue from left field: I don't think that I have a current text that addressed fetal monitoring, and I'm not really sure that I've attended any update/etc. that addresses the nuances of interpreting fetal monitoring since residency long, long ago. That said, I realize that interpreting strips is very subjective, and that fetal pulse ox (just heard an hour talk by Frank Boehm, Vanderbilt, about them--looks like we won't rely on monitors as much, I bet) may make monitoring history. Anyway, today I had an obese, insulin requiring gestational diabetic in labor. She was a primip at term, early labor at 2-3 cm/70%, due tomorrow, hurting, and not going home. AROM--meconium, internals placed, and when she didn't progress or contract enough, pit started. She had a normal strip, got an epidural, and then had recurrent lates, kind of deep, for about 45 minutes, with a loss of BTBV. The nurse didn't get too excited, saying that while they were deep, they came up ok, and then got "better" because they weren't as deep. The pit was stopped, fluids/Oxygen given, hypotension (a tiny bit) from the epidural corrected. The strip got better, meaning no decels, but no accels, poor BTBV, with the Pit off, and she wasn't contracting. BTW, she was 4 to 5/70/high, at about 3:30 PM--meaning that she has gone from 2-3 at 0830 to 4-5 by 1530! So, after discussion, the pit was started, the BTBV a bit better, no accels, contractions more frequent, and she had intermittent decels. As I had discussed with the patient, if we restarted the pit, and the strip began to "worsen"--whatever that means--then it was C/S time. OR trip, 8 pound, 14 oz. baby, Apgars 8/8. So, why did I present this? I was raised that a decel that was late typically started at the contraction's peak, and lasted beyond the contraction. However, if the form of the decel looked like a Nike swoosh, even if timed with the contraction, and no matter how deep, it was a late. The nurses seemed to think that a small decel--5 beats below the baseline in the form/morphology of a typical late, but that ended as the contraction finished, was of no concern? How do you decide? Who has a good book/website with pix? Garry
-- Garry E. Siegel, M.D., F.A.C.O.G. Roswell, GA Private Practice
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