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.