147. Momentum

In the final month of her pregnancy, 26-yr old Dolly experienced a "loss of vision" while driving. She managed to pull over and call the consulting nurse who told her to go to the urgent care clinic (instead of labor and delivery?). Urgent care called me, noting normal vision and normal blood pressure (one of the complications of the auto-immune disease involves hypertension). Send to L&D, I recommended, which they did.

I opened her chart: 4 prior pregnancies, all uncomplicated, moderate anemia (low blood count), and a recent diagnosis of an auto-immune disease, based on lab tests but not on actual symptoms.  Symptomatic auto-immune conditions increase risks of pregnancy complications.

L&D called me in my office, said the baby looked fine, normal blood pressure; OK, I’ll be there in about 15 minutes. Five minutes later, I got a call saying we need you right away, the baby’s heart rate has dropped. I was there in ten and found Dolly in the OR being prepared for an emergency cesarean, a decision made by another obstetrician who had been consulted in my brief absence.  He thought there might be a placental abruption (premature separation of the placenta, which leaves the baby without oxygen).

The baby’s heart rate was 80-100.  Normal is 110 or above, with rates in the 90-110 range considered tolerable for the short-term.  So no immediate crisis.  I put a hold on the proceeding, waiting for her to receive a full liter of intravenous fluid, which can revive a compromised baby. Waiting with me in the OR were two neonatal intensive care nurses, the anesthesiologist, two labor and delivery nurses, the OR technician, and the midwife who assists me with cesarean deliveries.  And of course the patient, who is freaking out. With the baby’s heart remaining low, but not critical, I decided to proceed with operative delivery. Too many unknowns--the visual thing, the prior diagnoses, the uncertain meaning of the fetal heart rate--and of course the momentum of a process set in motion 10-15 minutes earlier.

A vigorous baby with no sign of placental abruption or other problem, but over the next hour was noted to have a resting heart rate of 90-110 instead of the expected newborn rate of 110+. Add hypoglycemia (the patient had not eaten for about 10 hours at the time of the surgery) and her even lower blood count (blood drawn at arrival to L&D but not available until after the surgery).

So a combination of hypoglycemia, low blood level, and the baby’s naturally but not abnormal low resting heart rate contributed to what seemed like an emergency.  An unnecessary cesarean?  Maybe, maybe not.  But given the uncertainty and the momentum, pretty much unavoidable.