Emily was in labour for her first baby. Her pregnancy had been uneventful.
At 5cm cervical dilatation the midwife who was looking after Emily contacted me to say the baby’s heart rate pattern had become very abnormal and that she was concerned about baby’s wellbeing. An abnormal foetal heart rate pattern suggests lack of oxygen getting to baby, a condition we term as ‘foetal distress’. If it persists it is very dangerous and can result in brain damage for baby and even death.
I checked out the baby’s heat rate pattern (called cardiotocogram or CTG) on my office computer. I agreed with the midwife’s assessment. I advised for Emily to be given terbutaline (Bricanyl) 0.25mg (½ ampoule) subcutaneously. Bricanyl is a medication approved for relief of bronchospasm (abnormal contraction of the smooth muscle of the bronchi of the lungs, resulting in an acute narrowing and obstruction of the respiratory airway and so difficulty breathing). As Bricanyl relaxes smooth muscle it is also effective in stopping, or at least markedly reducing, uterine contractions. Emily did not have a Syntocinon infusion. Extra intravenous fluids were given (in case reduced fluid intake had been the cause) and Emily was also repositioned (in case there was umbilical cord being squashed by baby and so reducing blood flow in the cord).
The baby’s condition gradually responded to these intrauterine (in uterus) foetal (unborn baby) resuscitation measures. Contractions ceased temporarily after the Bricanyl injection. I attended, explained the situation to Emily and her husband and stayed with her for about 1 hour watching the foetal heart rate pattern on the monitor to make sure it remained normal. Emily was relieved all was ok. She was keen to avoid a Caesarean section.
When a woman is in labour the blood vessels in the uterine muscle that flow to the placenta are compressed each contraction. Baby only gets oxygenation between contractions. So, stopping contractions results in better oxygenation of baby. That is why baby’s condition improved after the Bricanyl injection.
Why Emily’s unborn baby got distressed is unknown. There was no background condition that would predispose her baby to this.
When I was comfortable that baby was ok, I returned to my office. Contractions had returned and all was well. Emily had an epidural block inserted. I watched her unborn baby’s CTG in my office, where I continued to see other patients.
About 4 hours later the very abnormal CTG pattern happened again. Emily’s cervix was now about 9cm dilated. I repeated the Bricanyl injection and again baby’s condition improved after the contractions temporarily ceased. I again attended and had discussion with Emily, her husband, and the midwife. I suggested another internal examination in about 2 hours. I advised I did not want Emily pushing when her cervix was found to be fully dilated. I said her pushing longer than needed would most likely result in further foetal distress and the need for an operative vaginal delivery. As well it would be hard for her to push effectively with a good epidural block. Passive descent of baby’s head in second stage labour when there is an epidural and no maternal desire to push is preferable and safer for baby. I advised I did not want Emily pushing until baby’s head had descended to the lower vagina (on view).
I later had a phone call saying baby’s head was on view. I instructed the midwife to start Emily pushing and I would attend. I arrived in time for the birth. Emily was successful in having a spontaneous vaginal delivery with an intact perineum and small vaginal tear. Her baby was born in good condition both clinically (excellent Apgar scores) and biochemically (excellent cord gases results). There was no reason at delivery for the foetal distress that had happened in labour.
Emily and her husband were delighted with my management of labour and so happy she did not have Caesarean section delivery.
When I sent this article to Emily for checking before posting in her e-mail reply to me she said: “There’s not enough words in the world to thank you for everything – our little boy is perfect, and my recovery has been so good.” Those words of affirmation are such a joy to read!
A Caesarean section delivery has surgical risks, would have had more painful postnatal course (Emily had no pain), would have implications for her next pregnancy and especially delivery, and Emily would not have had the personal satisfaction of pushing her baby into the world.
The midwife who supported me in looking after Emily had been a midwife for many years and was very experienced. She was very impressed by my care and said to me most obstetricians would have done a Caesarean section delivery. This was not Emily’s wish and Emily trusted my care. The next day Emily told me she was the talk of the postnatal ward as she had been able to avoid having a Caesarean section
I have been looking at CTGs and making decisions about baby’s wellbeing based on CTG patterns for several decades. In the past, we also checked baby’s scalp blood for supporting biochemical evidence of foetal distress when there was an abnormal CTG. When I was working at the John Radcliffe Hospital in Oxford England as a Senior Registrar, I did research that involved monitoring of baby’s oxygen and carbon dioxide levels in labour using a special scalp suction device (made by our bio-engineering department at the Hospital) attached by tubing to a mass spectrometer. I had a special research interest in foetal distress in labour and its management. As well, in contrast to what usually happens today, in the past a Caesarean section was only done if intrauterine resuscitation measures did not work.
I am certain I have more understanding and I am far more experienced at managing foetal distress in labour that most obstetricians. The easy ‘knee jerk’ response to an abnormal foetal heart rate pattern by most obstetricians today is a Caesarean section. This is a call made by the obstetrician whether or not the patient supports the decision and whether or not it is necessary. Considering Emily’s baby’s condition at birth in retrospect a Caesarean section would have been unnecessary and would have been the wrong decision. So many younger obstetricians today have little understanding and patience for intrauterine foetal resuscitation measures that can avoid Caesarean sections and so do Caesarean section deliveries unnecessarily.
