Following the 2008 NICHD update, our healthcare system identified the need to educate all members of the perinatal team regarding changes in electronic fetal monitoring (EFM) definitions, as well as, make changes to our current practice in regards to 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 impact 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 impact the future practice of the perinatal healthcare team.

Case:

This case involves a G₁P₀ at 39.6 weeks gestation with an uncomplicated pregnancy and a history of chronic hypertension. The patient presented to Labor & Delivery for cervical ripening and Oxytocin induction. Her admission tracing was Category I. During her Pitocin 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 C/S was performed. Full neonatal resuscitation ensued. APGAR scores were 0/1/2 at 1, 5 and 10 minutes respectively. Umbilical cord gas pH were 7.14 & 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 NICU 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 On day 13 of life, medical support was withdrawn due to severe hypoxic ischemic encephalopathy and renal failure after birth depression.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 impact the healthcare team.  The realization that “This can happen to us” serves as a catalyst for change. Until now, tachysystole was viewed as benign in the presence of reassuring FHR. 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.

Keywords:

Tachysystole

Electronic fetal monitoring (EFM)

Fetal oxygenation 

Culture change

Practice change