CASE 4: Meconium-stained fluid
A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.
The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.4
Considerations in CASE 4
- Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
- Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
- Administer supplemental O2. Increase IV fluids to facilitate utero-placental perfusion.
- If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
- When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
- Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
- Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
- Carefully review corresponding nursing notes. Always write your own assessment of events and actions.
Summing up: three “keepers”
First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.
Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.
Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.
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