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Keywords:

  • tachysystole;
  • electronic fetal monitoring (EFM);
  • fetal oxygenation;
  • culture change;
  • practice change

Paper Presentation

  1. Top of page
  2. Paper Presentation

Background

Following the 2008 National Institute of Child Health and Human Development update, our healthcare system identified the need to educate all members of the perinatal team regarding changes in electronic fetal monitoring definitions and to make changes to our current practice for early recognition and treatment of tachysystole. Multiple modalities of education were employed, especially surrounding the effects of tachysystole on the maternal-fetal dyad. Unfortunately, these efforts did not significantly affect actual practice.

Using a monthly strip review presenting the unexpected outcome of one patient, the multidisciplinary teams throughout the Baylor Health Care System gained a heightened awareness and understanding of the seriousness of tachysystole. This strip review generated discussion regarding the identification and appreciation of tachysystole and its effect on fetal oxygenation and fetal reserve. It was evident this case would affect the future practice of the perinatal healthcare team.

Case

This case involves a gravida 1 para 0 at 39.6 weeks gestation with an uncomplicated pregnancy and a history of chronic hypertension. The patient presented to labor and delivery for

cervical ripening and oxytocin induction. Her admission tracing was Category I. During her induction, she developed persistent tachysystole. Following fetal reserve depletion, the tracing deteriorated from Category I to Category III. Intrauterine resuscitation interventions resulted in a Category II tracing. Oxytocin was restarted. Consequently, the tracing deteriorated ending in a terminal bradycardia. A stat cesarean was performed, and full neonatal resuscitation ensued. APGAR scores were 0/1/2 at 1, 5, and 10 minutes, respectively. Umbilical cord gas and pH were 7.14 and 7.09, respectively. Initial neonatal arterial blood gas was pH 6.83, pCO2 19, bicarb 3.8, and initial blood sugars were in the 20s. The infant was stabilized, transferred to the neonatal intensive care unit, and whole body cooling was initiated. On day 13 of life, medical support was withdrawn due to severe hypoxic ischemic encephalopathy and renal failure after birth depression.

Conclusion

Traditional methods to implement change in practice are not always effective. Presenting real cases can truly affect the healthcare team. The realization, “This can happen to us” serves as a catalyst for change. Until now, tachysystole was viewed as benign in the presence of reassuring fetal heart rate. By demonstrating how tachysystole affects fetal oxygenation and reserve and how a physiologically normal fetus can suffer irreversible consequences, this case has empowered the healthcare team to be proactive in recognizing tachysystole and intervening sooner, thus allowing for better outcomes.