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Three R's speed response to prolonged hypoxia: rate, route, room.

SAN FRANCISCO -- Organize your thoughts when faced with complicated fetal heart rate tracings by remembering the three R's--rate, route, and room.

Clinicians commonly respond to fetal heart rate tracings suggestive of unremitting hypoxia by trying a host of routine interventions, some of which have uncertain efficacy, Michael D. Fox, R.N., said a meeting on antepartum and intrapartum management.

Random use of maternal position change, a fluid bolus, hyperoxygenation, stopping oxytocin, giving terbutaline, or stimulating the fetal scalp may dangerously delay the move to more effective interventions such as cesarean delivery, said Mr. Fox, director of the perinatal resource group at the University of California, San Francisco.

Rapid assessment of three key clinical variables speeds an effective response:

* Rate. Evaluate the fetal heat rate tracing to decide whether it's a true emergency or if further observation and conservative measures are appropriate. Reserve true "crash" C-sections for cases of sustained fetal bradycardia of 60 beats per minute (BPM) or less.

Most cases of fetal bradycardia need little or no intervention and resolve on their own, but it's difficult to tell which will be transient and which may be fatal. Even though no data support an absolute time frame for trying conservative measures, aim for delivering a fetus with bradycardia of 60 BPM or less within 10 minutes of the bradycardia reaching its nadir, Mr. Fox said at the meeting, sponsored by the university.

That means preparing to move the patient to the operating room if the bradycardia doesn't resolve within 3 minutes. Once there, surgical and anesthesia preparations can be combined while resuscitative measures continue and while waiting for the operating team to arrive.

For fetal bradycardia in the second stage, with a fetal heart rate between 60 and 80 BPM, assess heart rate variability. A fetus that loses variability either within 3 minutes of the beginning of the bradycardia or for more than 4 minutes during the bradycardia is more likely to become acidemic than a fetus that regains heart rate variability.

If this "end-stage" bradycardia persists with absent variability, and the patient is not about to deliver and does not respond to conservative measures, act as if the bradycardia were under 60 BPM and aim to deliver within 10 minutes. Also consider preparing for rapid delivery in cases with a persistent pattern of recurrent or late variable decelerations and absent variability, he added. If the heart rate pattern improves, consider continuing observation.

* Route. Decide whether a vaginal delivery is possible and whether you need assistance with forceps or vacuum to speed delivery Communicate the likelihood of successful vaginal delivery to the rest of the obstetrical team.

If vaginal delivery seems easy, move the equipment and personnel to the patient's location to avoid causing a delay by moving the patient to the operating room. If success is less certain but you want to try a forceps or vacuum delivery, move to the operating room to allow a smoother transition to C-section if the assisted delivery fails.

* Room. If the likelihood of vaginal delivery is remote and significant fetal acidemia is suspected, move the patient to the operating room and prepare for a C-section.

Tell the team whether you're calling for a rapid delivery or a true "crash" C-section. This affects the choice of anesthesia and prompts the operating room staff to shorten some surgical preparations if it's an emergency, he said.

Sherry Boschert

San Francisco Bureau
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Title Annotation:Obstetrics
Author:Boschert, Sherry
Publication:OB GYN News
Date:Oct 1, 2003
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