Talk to me about the fetal heart in active second stage!
I’ve long understood that transient decelerations with pushing contractions are quite normal in second stage (provided all else is well, etc etc etc) – yet today a more senior midwife “supporting” me as I attended a birth, went into mega-hyper-panic overdrive at the sound the these – oxygen by face mask, invasive VE, forced pushing (yes – I know – that just adds to the stress on the baby). In short, she did her utter best to make a perfectly *normal* birth (and I use the word very carefully, in view of a recent post of mine) into an abnormal delivery.
I was *shaking* with anger, yet so forceful is this woman that I felt any counter-argument on my part to be futile and upsetting the mother and her partner. In short, I was a weed – until the patron saint of midwives took pity on me and said midwife was relieved for her lunch break. Yah-hoo!!
But, seriously, like my question about the birth of the shoulders (to which I received so many helpful replies on and off list) – what are the limits of normality when it comes to the FM in second stage?
This is a difficult one – I reckon you’ve got to take each birth individually and be aware of the whole picture – you know, how long the woman has been labouring, how much energy she’s got, what the FH has been like first stage, recovery from decelerations – early? late? variable?, good progress, that sort of thing. And why was the woman being monitored continuously anyway?
What I don’t understand, in the scenario you painted is how come the supervising midwife went to lunch in the middle of what she obviously perceived as some kind of emergency? Or did I get that wrong? I’ve had this kind of intervention when I was a newly qualified midwife – we have monitors which show a CTG recording outside at the midwives’ station. I know – the answer to that is NOT to have a CTG recording at all, and do intermittent monitoring.
But in the particular case I recall – the FH was decelerating fairly precipitately, which led me to believe there was probably the cord loosely round neck – but it was recovering brilliantly and the vertex was on the perineum moving rapidly to birthing – when the Midwife in charge of labour ward BURST in through the door and started shouting about Reg. being on the way, and get O2 administered etc. etc.
The baby was born shortly thereafter through an unravelling cord, with excellent apgars, but we were all a little taken aback by the fuss. And I got a lecture about taking responsibility for my own CTGmonitorings… Seems to me that the CTG recordings that we really have to be concerned about are those much more subtle (often late) dips, with the accompanying lack of variability, not those horrendous, steep, variable decelerations which seem to accompany ‘cord around the neck’ scenarios.
The other time I have noted a horrible deceleration, often prolonged, in the FH is when the baby rotates from OP to OA – and the CTG then becomes normal, and can even be discontinued. Causes a few moments of anxiety.
I remember being terrified at what I now personally call a ‘second stage trace’ – deep early decelerations with rapid recovery to a variable baseline. What I do now (if I have been continuously monitoring for any reason) is take it all off providing descent and rotation are happening and listen in after each contraction. I’m not interested in early decelerations in second stage, so why bother hearing them?
Usually I have a student with me and her unease at the decels is picked up by the woman despite reassurance, I can’t blame the students, after all, I’ve already said that I used to be terrified!
I can also concur with Terri’s ‘rotation’ deceleration. I too have noticed this and, although it makes my heart thump a bit faster at the time, the trace invariably becomes perfectly normal following rotation and can be discontinued.
Whilst I appreciate that your experience means you are competent to ‘listen’ in rather than continuously monitoring, where does that leave you from a medicolegal perspective? If monitoring has been indicated in first stage, I can’t think of a situation where that would change in second stage. I know it’s sad that we have to ‘cover ourselves’ these days, but that seems to be the way things are, at least here in Australia
I always write a complete description of the trace and the reasons for taking my clinical decision. For example:
‘ctg – baseline 140bpm with excellent variability, accelerations present, some early decelerations with rapid recovery to baseline, uterine activity 1:2/3 fair to strong, clear liquor draining, no meconium. Plan: discontinue continuous monitoring, for intermittent auscultation following each contraction with return to continuous monitoring if lack of progress or other indication’
At a ‘midwives and the law’ study day, we were advised most strongly that we were more likely to be hung for failing to act on CTG than for not monitoring, provided we could justify the reasons for discontinuation of continuous monitoring. Giving good clinical reasons for discontinuing monitoring is, apparently, adequate for medico-legal reasons.
I would add, that I do not willy-nilly discontinue continuous monitoring, but with good variability, good progress, no meconium and rapid recovery from decels (provided that the decels are not late and do not occur in early labour or continuously) I am happy to listen in.
Had an interesting comment from a CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) person re CTGs. Not doing them doesn’t get you hung because what he’d noticed is that when midwives start getting worried listening intermittently, then action appears to happen faster. If it’s the CTG, the machine gets changed, it’s not believed, it’s not acted on and there are miles and miles of rope on which to hang yourself on!!!!
As long as you document why you’re not doing CEFM or why you’ve discontinued, you’re covered. And boy do I agree about OP to OA HR.
> What I don’t understand, in the scenario you painted is how come the > supervising midwife went to lunch in the middle of what she obviously > perceived as some kind of emergency? Or did I get that wrong?
No – she was just sent in to “support” me (as a recently Returned to Practice Midwife). Unfortunately, the FH chose that point to dip to 84 – and, yes, I think the head was rotating, cos it was fine a few contractions later. Also “unfortunately” the woman was not at that time pushing with visible effect (because (a) purple pushing is not my scene, and (b) she was waiting for her partner to return from buying sandwiches). So my supportive midwife took it upon herself to put me right on a few things, and it was awful. I still feel shaky thinking about it! I was trying hard to keep calm and in control for the woman’s sake.
At one point I stepped back form the bed, took of my gloves and quietly suggested that my “support” midwife took over, since she obviously had a better grip on the situation. I tried to keep all this very quiet and discreet, and I don’t know if the parents were even aware (I hope not – there was a senior student standing with them at this point, so we midwives weren’t the centre of attention).
I’m not sure if I’m proud or not of doing this, but it made me feel better – at the time. The senior midwife refused to take over, saying it was “my delivery”, so I resumed my place. Then she was relieved for lunch.
I agree with CTGs causing their own problems. I was initially only using a doppler, until all the excitment happened.
Thanks for your support.
I am only a first year student but from reading what you have said I think you handled the situation well.
By standing back from the situation you offered the other midwife the opportunity to take over. It seems to me that by doing this you gave her the opportunity to think about her own role in the event and the fact that she agreed to be relieved for a break shows that maybe she was not as concerned as she initially showed. Had she been concerned about your ability to cope with the situation I would have thought she’d have stuck around for the outcome.
I think you showed a cool head in a tense situation. Well done
What was the rationale for the midwife’s statement that “this (moving the mother onto her hands and knees) was not allowed as she had an epidural”?
The midwife I was working with did not give a reason for her refusal to try an all fours position except for the epidural factor. I personally feel that there is no point introducing epidurals that allow limb movement if the woman is not given the opportunity to try to move. I am not suggesting that women should be running around the birthing room with an epidural in situe, but I did not feel that my request was unreasonable.
I did not challenge the midwife for two reasons. Firstly I did not wish to challenge her in front of the woman (known to me already) and her partner and secondly I did not wish to make an enemy in my first week on placement.
I remember being terrorised by senior midwives because,in their opinion I was not picking up on ropey fetal hearts in 2nd stage and getting the reg in to do forceps( ventouse was not in fashion then) and a number of times they would just wander in even when the case was nothing to do with them.
I have a real issue with the use of CTGs. My feeling is that they are the cause of so much of this stress with no bearing on the outcome. In fact my own experience is that they probably cause a lot of the problems that would be put down to the fetal distress because they prompt invasive action when it is often not needed, but if you have the thing on then I suppose you are going to act on it. No wonder they show up stressed babies when the woman is immobile (however hard you try it is not the same kind of mobility if you have a CTG on you) she has a major bit of electrical equipment strapped to her body,possibly a bit of wire stuck up her vagina, pinned into her baby’s head and attached to a power supply. No wonder people on them get stressed and then the baby gets stressed.
My own feeling is also that scalp electrodes are barbaric and that the baby must be in pain from it which probably gets it all agitated and shows up as distress. Imagine yourself with the equivalent of a, very large suture needle pushed into your scalp for hours. How would you feel? I also seem to remember that CTG were very unreliable in 2nd stage and often the woman was made to stay in a position where the thing picked up the heart. Whether she was comfy or could push like that didn’t seem to matter as long as the trace showed up. I could bang on forever about CTG and what I think they do to labour but you probably get my drift from this.
In my own practice now I use a sonic aid or a Pinards stethoscope; the woman has the choice. My colleague and I have both detected fetal distress of a serious nature with intermittent auscultation and transferred in. The result both times was a section on arrival, but in my case not before the staff had said the CTG must be broken and searched around for another one delaying the section – my suggestion when on the phone to the labour ward was to scan stat to see if the heart was doing what I thought it was, but no they had to waste time with the CTG. In the end both babies were delivered safe and well.
The person who said you get to know a baby’s heart beat is right; My colleague and I feel there are enormous benefits for all concerned that we always listen to the heart at each visit, and we do all the visits. if there are any little quirks or influencing factors we get to know them.
I know there may be times when a CTG has prompted appropriate action, but it may well have been the same with intermittent auscultation.
What are we doing using CTG on normal women anyway? We all know the proof is it does not improve outcomes for the baby and probably lands the woman with a giant episiotomy. NO SORRY I don’t rate CTG and I think we should be trying to use them less and less on all women, but especially the ones who are expected to be normal.
If you are listening with the Pinard or Sonicaid you have to go to the woman and have a conversation with her about how she feels, and see her during a contraction, palpate her baby etc – all good stuff if you ask me. We have all gone into a room only to find what was mean to be a 20 minute trace is now 2 hours’ worth of paper all over the floor because we got tied up with another client.
I am glad I don’t have to work that way any more; those people used to sabotage my births, zap my self-esteem for days, and make me feel like a rubbish midwife – all based on what was showing on the CTG. I don’t feel like that anymore.
Elaine (independent midwife)
From MIDWIFERY MATTERS, Issue No. 82, Autumn 1999
Midwifery Guidelines Response
Dr John Stevenson
Foetal Heart Rate Monitoring
When I began attending home births, I made it my rule to listen to the foetal heart hourly during first stage, and quarter-hourly during second stage. Of course any abnormality detected would warrant listening far more often, but that hardly ever happened. I think the standard fifteen seconds is adequate, rather than a full minute.
The foetal heart generally remains normal throughout first stage. But in assessing this, it is important to know what the usual reading was throughout pregnancy, and also allow for the time of day. (I once detected a rate of only 100 at 3 am.)
Problems can arise if you do not know what variations to expect in second stage. For most of second stage the foetal heart usually remains normal, but some babies’ hearts can become erratic in second stage, without indicating any serious problem. Some babies are sensitive and excitable. Moulding of the skull can be a stimulus.
When the baby’s head is on view, you should not try to check the heart, because it sometimes happens that the oxygen is cut off when it has descended to the perineum, owing to shrinkage of the uterus over the placental site, cutting off maternal supply to the placenta. When this happens, the baby’s heart slows drastically, and if you don’t expect it, you could think that the baby was in trouble, when actually it isn’t, because the slowing of the heart is a reflex action to conserve oxygen, but baby is quite safe because the normal polycythaemia in term babies ensures very adequate reserves of oxygen.
Even when baby becomes blue, it is not in danger, it still has reserves. A shocked baby is not blue, but pale grey. If you detect a slow heart when the head is on view, all you need to do is tell yourself that baby must be delivered within twenty minutes. It will usually pop out in a fraction of that time.
For the rest of this article, see Midwifery Guidelines Response, by Dr John Stevenson
AH updated 12 November 2000