Question for HB Midwives - Ever dealt with Fetal PAC's??

[ItzKel]

Hello ~ I am currently 38 1/2 weeks pg (EDD 10/7/10) and am planning a homebirth, my 2nd one. Last week at my home visit with my MW, she noticed an arrhythmia with the baby's heartbeat and was only able to count the heartbeat at 100bpm, then in the 70's. She at first planned to have me see the local Perinatologist in the afternoon to have him check this arrhythmia, but after checking the heartbeat and getting it in the 70's, she had me go to the closest hospital for monitoring right away. When we got there, the monitors could not even get an accurate reading AT ALL and if anything it was showing 55bpm (but never giving a green light). The OB brought in an ultrasound machine and right away you could see the heartbeat and also the arrhythmia (at around 155bpm according to the u/s). They then had a radiology tech come in with the big ultrasound and do a full scan on the baby, including measurements, heart, amniotic fluid, etc. This was then sent to the same perinatologist my MW had originally wanted me to see. While waiting to hear back from the specialist, the OB (who was VERY nice) was answering some of my questions to the best of her ability without having heard back from the specialist. She said in her experience, the specialist will likely want to have the baby born today since I was past 37 weeks (this was last week when I was 37 weeks, 5 days pg), and that likely since we are seeing a heart issue/arrhthymia, he will suggest a csection in order to not put undue stress on the baby's heart during labor. Totally made sense to me. We finally heard back from the specialist who said it looked like an arrhythmia that will go away once the baby is born, but wanted to see me in his office in an hour. So DH, my MW asst and I go up to his office and his tech does an u/s and says the DR will be in shortly. He comes in 20 minutes later and says I have a normal pg and my baby is experiencing PAC's (premature atrial contractions) that are benign and will go away once the baby is born. He says I am free to have the baby at home or hospital, and that the biggest issue is the added stressor on whomever is delivering me because of getting the inaccurate heartrate due to this benign arrhythmia. He said he gets 2-4 patients in his office per week with this condition and he isn't worried about it, but that it does tend to lead to a lot of "unnecessary c-sections" which I imagine it's because the heartrate appears to drop when in fact there is no REAL issue. Soooo, I spoke to my midwife and she was fine with everything and had planned to talk to the specialist personally to touch base with him.

So, fast forward to today and I go in to hear the baby's heartbeat (we planned for me to come in 2X per week after this event just to check the heartbeat more often). We can still hear the arrhythmia and at times can count the heartbeat in the 140's, and at others it sounds low (70s?) due to the skipped beats. My MW alluded to saying that if this happens in labor, she is going to want to get it checked, which I took to mean we would be going to the hospital to monitor it. I am HOPEFUL that, because she hasn't talked directly with the perinatologist, she hasn't determined yet how to tell the difference between a true decel of the baby's heartbeat (ie. baby was in true distress) vs. a low heartbeat count due to the arrhythmia. While I want a homebirth, I am not comfortable going into one if my MW is not comfortable with the likelihood we will be experiencing this arrhythmia throughout labor. I know in the hospital they said they could get the most accurate reading of the heartbeat by an internal monitor in the baby's scalp...

My question is (and thanks for being patient with my story!) have any Homebirth MW's experienced PAC's with your patients during a homebirth? Was this a known condition on your end? How, if at all, were you able to determine if a low heartrate count was due to the arrhythmia or a true decel of the baby's heartbeat? Thanks for any and all advice/recommendations you may have.


Kelly

Mom to J (natural hospital birth, 8/05), J (homebirth, 7/7) and due with J (planning homebirth 10/7/10)

[Sijae]

I just attended a labor with a baby that had PVC (premature ventricular contraction). Basically every 3 beats there was a premature beat and then a longer pause (both normal pauses put together) and then a resumption of beats. It happened consistently throughout the labor and resolved with birth.

I think the advice the perinatologist gave you is great! It is benign, it will clear up, and apparently he was right about provider stress. If it were me, I would make it clear to the midwife that I was comfortable with the diagnosis and that I wanted to proceed with the homebirth regardless of FHT during labor.

There's no way I would personally put myself and my baby through the significantly added risk of a cesarean (especially a pre-labor cesarean) because of a benign murmer and the midwife's inability to accurately monitor the heart during labor. There's also no way I would subject us to the added risk of cesarean and intervention in a hospital birth. I would trust that my baby was fine and that the birth would be fine.

[ItzKel]

Hi Laura ~ thanks for your response! Did you or the MW have issues figuring out the accurate heartbeat for the baby during labor? Was there a way you were able to 'compensate' for that skipped beat in order to gauge if the baby's heartbeat was in the normal range?

[rnchrista]

I attended the birth of a baby with PACs a little over a year ago. I discovered it prenatally and sent her in for a fetal echo to make sure nothing significant was going on, and it wasn't. The peri gave me the same advice, that this would disappear shortly after birth.

You can't do just a quick count for heart tones and expect it to accurately reflect what the FHTs really are. If the PACs are irregular and you do a 10 second count and get a couple skipped beats and then multiply it by 6 to make a full minute (as you normally would in a baby without an arrhythmia), you probably won't end up with a true heart rate number. If you end up counting for a full minute, you'll probably have something close to the normal range.

Also, even though I didn't pick these up on the client till 36 weeks, I felt like by the time she gave birth, I'd listened enough times prenatally to know what was normal for the baby. I would definitely be able to identify a PAC vs a concerning decel during labor.

[Jane]

I've only attended a birth with a babe that did it very intermittantly.
I would recommend having a fetoscope on hand. Sometimes it's easier to listen directly without the technology involved.

[Sijae]

We were still able to get reasonable counts overall. Baby had great variability and 5 second counts never went below 9. Other than the long pauses which sounded like skipped beats, the patterns were the same as in other labors. I feel like we would have been able to distinguish a late decel from the arrhythmia without any problem.

ETA: it sounds like it was a little different from yours in which it was difficult to get a reasonable count. I second the idea to use a fetoscope and listen for longer periods of time.

[babyjelly]

My second child has PACs (which did not actually resolve with birth, but are still benign). I birthed her in the hospital, not because of the arrhythmia. She did have decels after membrane release, and honestly- the decels sounded nothing like the arrhythmia. It was completely different. I would absolutely go forward with a homebirth in your shoes.
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[ItzKel]

Thank you so much for your responses! I had a very good talk with my MW yesterday after she had finally consulted with the perinatologist who I had seen. It sounds like he gave her some great advice as well about differentiating between an arrhythmic 'psuedo-decel' vs. a true decel. The main thing is that SHE is confident and comfortable and therefore my confidence is back in full swing. I think we may have had some other miscommunications but it looks like we now are on the same page and my stress level is SO much lower, I feel normal and excited about my upcoming labor and birth again! Now it's all about waiting to see when my baby girl decides to make her appearance - my EDD is a week from tomorrow (10/7) and with both my boys I went into labor naturally on their EDD's so we shall see...

Thanks again for your feedback - your reassurance and experience with PAC's really meant a lot to me to hear.