A 22-year-old G3P2 woman at 40 weeks’ gestation complains of strong uterine contractions. She denies leakage of fluid per vagina. She denies medical illnesses. Her antenatal history is unremarkable.
On examination, the blood pressure (BP) is 120/80 mm Hg, heart rate (HR) is 85 beats per minute (bpm), and temperature is 98°F (36.6°C). The fetal heart rate is in the 140 to 150 bpm range. The cervix is dilated at 5 cm and the vertex is at –3 station. Upon artificial rupture of membranes, fetal bradycardia to the 70 to 80 bpm range is noted for 3 minutes without recovery.
What is your next step in management of this case?
Answer And Discussion:
Management:
It is important to consider following important points in the management of this case:
1.The first step in the evaluation of fetal bradycardia in the face of rupture of membranes should be to rule out umbilical cord prolapse.
2. The treatment for cord prolapse is emergent cesarean delivery.
3. An unengaged presenting part, or a transverse fetal lie with rupture of membranes, predisposes to cord prolapse
Important Considerations: This patient has had two prior deliveries. She is currently in labor and her cervix is 5 cm dilated. The fetal vertex is at –3 station, indicating that the fetal head is unengaged.
With artificial rupture of membranes, fetal bradycardia is noted. This situation is very typical for a cord prolapse, where the umbilical cord protrudes through the cervical os. Usually, the fetal head will fill the pelvis and prevent the cord from prolapsing. However, with an unengaged fetal presentation, such as in this case, umbilical cord accidents are more likely. Thus, as a general rule, artificial rupture
of membranes should be avoided with an unengaged fetal part. Situations such as
a transverse fetal lie or a footling breech presentation are also predisposing conditions. It is not uncommon for a multiparous patient to have an unengaged fetal head during early labor.
The lesson in this case is not to rupture membranes with an unengaged fetal presentation.
With fetal bradycardia, the next step would be a digital examination of the vagina to assess for the umbilical cord, which would feel like a rope-like structure through the cervical os. If the umbilical cord is palpated and the diagnosis of cord prolapse confirmed, the patient should be taken for immediate cesarean delivery. The physician should place the patient in Trendelenburg position
(head down), and keep his or her hand in the vagina to elevate the presenting part, thus keeping pressure off the cord.
Steps To Take With Fetal Bradycardia:
- Confirm fetal heart rate (vs maternal heart rate)
- Vaginal examination to assess for cord prolapse
- Positional changes
- Oxygen
- Intravenous fluid bolus and pressors if hypotension persists
- Discontinue oxytocin
Fetal Heart Rate Assessment: The baseline fetal heart rate is normally between 110 and 160 bpm, with fetal bradycardia less than 110 bpm, and tachycardia greater than 160 bpm. The fetal heart rate
typically has moderate variability, whereas diminished variability may be caused by sedating medications or more rarely fetal acidosis. Accelerations are abrupt increases in fetal heart rate of at least 15 bpm lasting for 15 seconds, and typically are indicative of adequate fetal oxygenation. Decelerations may be early, late, or variable depending on its configuration and timing with the uterine contraction
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