Obgyn · Year 3 · from Obgyn
Case 1: Emergency Cesarean for Non-Reassuring Fetal Status
Patient Demographics
- Age: 29 years
- Sex: Female
- Occupation: Marketing manager
Chief Complaint
"I'm in labor and something seems wrong with the baby's heartbeat."
History of Present Illness
The patient is G1P0 at 39 weeks 4 days admitted in spontaneous labor. She presented with regular contractions and ruptured membranes with clear fluid. Initial cervical exam was 5 cm dilated. Labor progressed normally until she reached 8 cm dilation when the fetal heart rate tracing became concerning.
Labor Course
Admission:
- Cervix: 5 cm, 80% effaced, 0 station
- FHR: Baseline 140, moderate variability, accelerations present
- Membranes ruptured; clear fluid
At 8 cm (6 hours after admission):
- Epidural in place, comfortable
- Contractions every 2-3 minutes
- FHR changes noted:
- Baseline rising to 170 bpm (tachycardia)
- Variability decreased to minimal
- Recurrent late decelerations with each contraction
Fetal Heart Rate Interpretation
Category III Tracing:
- Absent variability with recurrent late decelerations
- Indicative of ongoing fetal hypoxia/acidosis
Intrauterine Resuscitation Attempted
Interventions:
- Position changes (left lateral, right lateral, hands and knees)
- IV fluid bolus (1 L lactated Ringer's)
- Oxygen by face mask at 10 L/min
- Discontinue oxytocin (was running for augmentation)
- Cervical exam: 8 cm, no cord prolapse
Response:
- No improvement after 10 minutes
- Persistent late decelerations with minimal variability
- Decision: Emergency cesarean delivery
Cesarean Delivery
Indication: Non-reassuring fetal status (Category III tracing unresponsive to resuscitation)
Timing: Decision-to-incision interval: 15 minutes
Procedure:
- Pfannenstiel skin incision
- Low transverse uterine incision
- Delivery of male infant in cephalic presentation
- Nuchal cord x 1 reduced at delivery
- Moderate meconium-stained fluid noted (not present on initial ROM)
Neonatal Outcome
- Male infant, 3,450 grams
- Apgar scores: 5/7/9 (1, 5, 10 minutes)
- Cord gases: pH 7.08, base excess -12 (metabolic acidosis)
- Vigorous at birth after stimulation
- NICU observation for 4 hours, then to newborn nursery
- No sequelae at discharge
Postoperative Course
- Routine post-cesarean recovery
- Ambulating POD 1
- Tolerating regular diet
- Hemoglobin stable
- Discharged POD 3
Counseling for Future Pregnancies
- Discussion of TOLAC vs. elective repeat cesarean
- Low transverse incision: eligible for TOLAC in future pregnancy
- Success rate for TOLAC without prior vaginal delivery: 60-70%
- Uterine rupture risk with low transverse: 0.5-1%
Clinical Image
Image Description: Fetal heart rate tracing demonstrating Category III pattern with absent variability and recurrent late decelerations. The tracing shows a rising baseline with minimal beat-to-beat variability and late decelerations that begin after the peak of contractions and return to baseline after the contraction ends.
Attribution: Educational illustration. Adapted from ACOG fetal heart rate interpretation guidelines.