Question

CASE STUDY 2

Renee is a 22-year-old G2 P0 at 42 weeks of gestation in active spontaneous labor. Her pregnancy has been complicated by mild hypertension, but no medications were needed. She is 4 cm/100/0 station, vertex position. Her membranes have just ruptured, and there is thick meconium staining. She is comfortable and using epidural anesthesia.

1. What risk factors are present that may impact the way this fetus tolerates labor?

2. The fetal heart rate shows a rate of 140, moderate variability, no accelerations, and decelerations to 120 beginning after the peak of most contractions and recovering to baseline 30 seconds after the contraction ends. Contractions are every 4 minutes. How should the nurse describe this pattern?

3. What should the nurse do at this point?

4. Renee is now 8/100/0. She is in the left lateral position with oxygen at 8 liters/minute. The fetal heart rate is 145. There is moderate variability. Accelerations are not present. There are decelerations in the fetal heart rate beginning at the onset of a contraction, descending to 120 with recovery by the end of a contraction. The contractions are every 3 minutes now. How would the nurse describe the fetal heart rate pattern now?

3. Renee is now completely dilated and +1 station. She has been instructed to push with every contraction. The fetal heart rate is now 164. There is absent variability and decelerations to 120 are occurring with maternal pushing, which do not resolve until 30 seconds after the contraction. The contractions are every 1½ minute. How should the nurse describe this pattern?

4. What should the nurse do in this situation? NO PHOTOS PLEASE THANKS

Answer 1

• What risk factors are present that may impact the way this fetus tolerates labor?

(a.) 42 weeks of gestation.
(b.) Mother with hypertension.
(c.) Meconium-stained amniotic fluid.

A fetus at 42 weeks of gestation may have less ability to tolerate the stress of labor than at 39 to 40 weeks of gestation. There is an increased incidence of uteroplacental insufficiency, and perinatal deaths are higher at 42 weeks than at 40 weeks. The additional risk factor of hypertension makes uteroplacental insufficiency more common. Passage of meconium can be a sign of fetal hypoxia and puts the fetus at risk for meconium aspiration syndrome.

The fetal heart rate shows a rate of 140, moderate variability, no accelerations, and decelerations to 120 beginning after the peak of most contractions and recovering to baseline 30 seconds after the contraction ends. Contractions are every 4 minutes. How should the nurse describe this pattern?

This is a category 2 fetal heart rate tracing. Although recurrent late decelerations are present, the presence of moderate fetal heart rate variability prevents it from being a category 3 tracing. There is no tachysystole.

The presence of moderate variability is reassuring; however, the late decelerations combined with the meconium staining, postdate, and hypertension mandate very close observation.

• What should the nurse do at this point?

With meconium stained fluid and late decelerations, the nurse should notify the provider to evaluate the fetal heart rate tracing. The nurse should also do the following: (a.) Position the mother in a lateral position

(b.) Increase IV hydration

(c.) Administer oxygen by face mask to the mother at 8 to 10 liters

(d.) Check maternal blood pressure

(e.) Document her findings, the notification of the provider and the actions taken, and their results

(f.) Communicate to Renee and her family clearly what is occurring and why the interventions are being done.

The lateral position increases uteroplacental blood flow by avoiding aortal or vena caval compression with the supine position. Hydration is increased to expand the maternal blood flow and perfusion to the uterus/placenta. Maternal administration of oxygen may make more oxygen available to the fetus. Hypotension is a common side effect with epidural anesthesia, and if present, can be a contributing factor to uteroplacental insufficiency. It can be corrected with medications. Accurate and timely documentation is important in all nursing care, but especially in a high litigation area like obstetrics.

• Renee is now 8/100/0. She is in the left lateral position with oxygen at 8 liters/minute. The fetal heart rate is 145. There is moderate variability. Accelerations are not present. There are decelerations in the fetal heart rate beginning at the onset of a contraction, descending to 120 with recovery by the end of a contraction. The contractions are every 3 minutes now. How would the nurse describe the fetal heart rate pattern now?

The heart rate remains in a normal range. The moderate variability is normal. The decelerations described are early decelerations. This is now a category 1 tracing.

The normal fetal heart rate is 110 to 160 so the rate is normal. The presence of moderate variability continues to be a reassuring sign, and the presence of early fetal heart rate decelerations are considered normal with the head compression occurring with descent. Although this is now a category 1 tracing, continued vigilance is needed because of the other risk factors of postdate, hypertension, and meconium.

• Renee is now completely dilated and +1 station. She has been instructed to push with every contraction. The fetal heart rate is now 164. There is absent variability and decelerations to 120 are occurring with maternal pushing that do not resolve until 30 seconds after the contraction. The contractions are every 1½ minutes. How should the nurse describe this pattern?

The fetal heart rate is now tachycardic. The variability is absent and early and late decelerations appear to be present. There is also tachysystole. This would be a category 3 tracing.

The combination of absent variability, tachycardia, and late decelerations suggest deterioration of the fetal acid-base balance, which could result in fetal acidemia and hypoxia.

• What should the nurse do in this situation?

The nurse should:

(a.) Notify the provider to come to the bedside immediately.

(b.) Notify the OB team that an operative vaginal delivery or C/S may be needed.

(c.) Discourage Renee from pushing and allow her to labor down with contractions.

(d.) Anticipate possible order for terbutaline subcutaneously.

(e.) Prepare for infant resuscitation.

(f.) Explain all concerns and actions being taken to Renee and her family.

With the onset of pushing, the fetal heart rate displays deterioration. The contractions are too closely spaced and do not allow time for the fetus to recover. The interventions of terbutaline to space the contractions and laboring down rather than pushing may allow the fetus to recover and progress to normal delivery. If however, with these interventions, the fetal heart rate pattern remains the same, expedited delivery via C/S or operative vaginal delivery would be indicated. This is a frightening time for Renee and her family, and the nurse must communicate clearly and calmly.