Interventions for Late and Variable Decelerations (Nursing)

by Jacquelyn McMillian-Bohler

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      Slides Fetal Monitoring Basics Nursing.pdf
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      Slides Fetal Monitoring Interventions for Late and Variable Decelerations Nursing.pdf
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    00:01 Let's move forward.

    00:02 So remember our picture of our late deceleration? So do you remember what that looks like? Might want to draw that out on your piece of paper in relationship to the contraction.

    00:12 Hopefully, you have a fetal heart rate and a contraction.

    00:17 The contraction begins and then the heart rate drops and then the contraction is over. And then long after the contraction is over, the heart rate goes up to baseline.

    00:27 That's a late.

    00:29 We know that's associated with poor oxygenation, so what do we do? The first step is we're going to reposition the patient, think about the ABCs.

    00:38 If we're going to do CPR, the first thing we do is position the patient so that we can open up the airway, or we're going to reposition the client in this case so that we can improve the oxygenation.

    00:50 So reposition, usually it's left lateral, but if you've been on the left, try right, try sitting up, whatever works, just reposition.

    00:58 The next thing we're going to do is if the client has been receiving oxytocin or pitocin in order to stimulate the uterus and cause contractions, we're going to turn that off. Remember the idea of tocolysis? The contraction is what's causing the deceleration.

    01:13 So let's stop it.

    01:14 We're going to turn off the oxytocin and make that happen.

    01:17 So we'll do that next.

    01:19 Then we're going to think about increasing maternal saturation of O2.

    01:23 We're going to give oxygen at least around 10 liters per minute.

    01:27 We're going to use a non-rebreather mask.

    01:30 Then, if we need to give fluids, PO fluids are not going to work.

    01:33 We want to increase the blood viscosity, so we're going to give a bolus of IV fluid.

    01:39 Now, two things you want to be really careful of.

    01:42 One is that you're giving a fluid that doesn't contain a lot of glucose because we're going to give a lot of fluid right here and we don't want to increase the maternal glucose level.

    01:51 The other thing is, if you have a patient who is on fluid restrictions because of a cardiac issue or because of preeclampsia, we don't want to give a lot of extra fluid because we can actually cause pulmonary edema or other kinds of complications that are related to fluid overload.

    02:06 So be very careful and mindful about that.

    02:10 Now, let's say we've tried to reposition, we've turned off the oxytocin, we turned on the oxygen, we've given a fluid bolus and the heart rate is still continuing to experience these decelerations, then we may need to check the cervix next to see how close this client is to delivery.

    02:25 So let's say we're experiencing these late decelerations with every contraction and the patient is 2 centimeters.

    02:33 That's a very different story than a client that's 9 or 10 centimeters and getting ready to deliver soon. And likely we're going to do the next thing, which is to call the provider. And that's most likely going to be one of the very first questions they ask.

    02:46 So going back through, we're going to reposition, turn off the oxytocin, start oxygen, 10 liters a minute.

    02:54 We're going to give a fluid bolus, being careful of any patient that has fluid restrictions. We're going to check the cervix, and then we're going to call the provider with information about what has occurred.

    03:04 Now, let's talk about interventions for variable decelerations first.

    03:09 Any time we see any sort of unfavorable fetal heart rate tracing, decrease variability, decrease heart rate, late decelerations, variable decelerations, we're going to reposition the client to the left side.

    03:23 This is the way that we can increase the cardiac output and get more oxygen to the baby. Now, I'm going to add we also, with variable decelerations, are going to reposition the client as a way to move the baby and the cord so that we can decrease compression.

    03:39 So we get a two for one deal with repositioning, increasing the cardiac output and then potentially, hopefully, moving the cord.

    03:48 Next, if the client has been receiving oxytocin for an induction or augmentation of labor, we want to turn it off.

    03:56 Every time the uterus contracts, it decreases blood flow.

    04:00 It decreases oxygen, which is not what we want to do if we're having an issue with cord compression. Speaking of oxygen, this one is exactly the same as late decelerations. We want to give oxygen via a non-rebreather mask at 10 to 12 liters per minute.

    04:16 Moving on to the next intervention, we want to consider giving a fluid bolus.

    04:20 This is the way that we can increase the circulation of the fluid through the body and increase the oxygen.

    04:26 Always be mindful that if the client is at increased risk for pulmonary edema or congestive heart failure, then we might want to give a smaller bolus or maybe no bolus at all when we get to the cervical exam.

    04:40 Think about why we're doing it with the late decelerations.

    04:43 We're checking to see how close the client is to delivery.

    04:47 That's also true with variables, except we have the second issue of the cord compression. So we also need to see if we can feel a cord or see a cord. A prolapsed cord is a condition when the cord is coming before the presenting part, and it might be the etiology for the variable decelerations we see on the monitor. So, again, this is kind of a twofold intervention, we'll do the cervical exam to check the status of the labor and also to check for a court.

    05:16 Now, we'll move to the next intervention, which is calling the provider.

    05:19 When we call, we can give them an update on everything that's been done so far, the outcome and how close the client is to delivering, maybe in the case of a variable decel, whether or not a cord was palpated or observed.

    05:33 Now you'll see a slightly different intervention at the bottom.

    05:36 This is intervention number seven, amnioinfusion.

    05:40 It looks very similar to a fluid bolus, the one that's hanging on the IV pole.

    05:45 That part's true.

    05:46 But the fluid we're going to use in this case is usually normal saline and instead of going through a peripheral IV into the arm, it's actually going to go into the uterine cavity. It'll go through a fluid warmer and then into the uterus.

    06:01 Now, with this fluid, we're going to hopefully increase the amount of fluid that's in the uterine cavity and float the cord.

    06:09 This provides a cushion and may decrease cord compression.

    06:13 So that's an amnioinfusion.

    06:15 Keep in mind that the nurse would never, ever, ever start an amnioinfusion without a separate order from a provider.

    06:23 This would not be a standing order.

    06:26 Now, sometimes we need a little mnemonic to sort of help us remember the reason why things happen and what we do about it.

    06:33 We have one actually for these decelerations known as veal chop.

    06:38 So this is veal chop.

    06:40 Now, I'm a vegetarian, so veal chops are not something I would eat.

    06:44 Totally not the point.

    06:46 The point is that we're going to remember the etiology of all of these changes.

    06:50 Variables are caused by cord compression.

    06:54 See that? See where we're going.

    06:56 If we have early decelerations, they're caused by head compression.

    07:02 Yeah. If we have accelerations, guess what? They're OK.

    07:07 We like those.

    07:09 If we have late decelerations, they're caused by placental insufficiency. So now we have veal chop, so when you have a question about what is the etiology of a variable or the etiology of an early decel or anything else, you can say veal chop.

    07:27 Well, you can actually say what the letters stand for, but you get the idea.

    About the Lecture

    The lecture Interventions for Late and Variable Decelerations (Nursing) by Jacquelyn McMillian-Bohler is from the course Fetal Monitoring (Nursing).

    Included Quiz Questions

    1. Reposition the client
    2. Stop oxytocin immediately
    3. Give oxygen 10 liters per minute
    4. Give bolus of IV fluid
    5. Perform a cervical examination
    1. Increase oxygen to at least 10 L/pm to increase oxygenation to a client with late decelerations.
    2. Give oxygen at least 2 L/pm to increase oxygenation to a client with late decelerations.
    3. Reposition the client to the Trendelenburg position to increase oxygenation with late decelerations.
    4. Early decelerations are caused by cord compression.
    5. Variable decelerations are caused by head compression.

    Author of lecture Interventions for Late and Variable Decelerations (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler

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