Several years ago Myra delivered a healthy 7 pound girl; a couple of days ago she presented at one week after her due date with spontaneous rupture of membranes. Labor progressed slowly, augmented by the contraction-stimulating hormone oxytocin (Pitocin). Fetal heart monitoring was abnormal with several episodes of bradycardia (heart rate less than 110 for more than three minutes). Bradycardia prevents inhibits normal delivery of oxygen to vital organs.
Each episode resolved spontaneously, but the concern remained that the next bradycardia might persist, causing permanent damage. Severe bradycardia (less than 60) cannot be tolerated for long; even a fetal heart of 100 or so can result in fetal harm if continues more than 30 minutes. So we faced the decision whether to interrupt labor by performing a cesarean delivery.
We hesitated because between the bradycardia episodes the heart monitoring was reassuring (no subtle signs of fetal distress) and because labor was progressing. We became hopeful when she made it to complete dilation but the first push triggered another bradycardia. At about 8 minutes into this episode, we recommended and Myra accepted cesarean delivery. The baby was vigorous at birth, with no explanation for the bradycardia.
Based on the exam (the baby’s heady was well descended into the birth canal), and her prior delivery (proving an adequate birth canal), I estimated that a vaginal delivery was only 10-20 minutes away. If she had requested a continued trial of labor, I would not have objected. But she didn’t. It’s a joint decision--in the current parlance, “shared decision-making," and that 10-20 minutes could be devastating.
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