A nurse is assisting with the care of a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.



Which of the following actions should the nurse take?

Choice A rationale:

Umbilical cord compression is the most common cause of variable decelerations. It occurs when the umbilical cord is

compressed, momentarily reducing blood flow to the fetus and causing a decrease in fetal heart rate.

Variable decelerations are characterized by their abrupt onset, variable duration, and unpredictable shape. They typically

recover quickly to the baseline fetal heart rate after the compression is relieved.

Several factors can contribute to umbilical cord compression, including:

Fetal movement: The fetus can sometimes move in a way that compresses the cord, especially during active labor.

Oligohydramnios (low amniotic fluid): With less amniotic fluid, there's less cushioning around the cord, making it more prone

to compression.

Nuchal cord (cord around the neck): If the cord is wrapped around the fetus's neck, it can become compressed during

contractions.

Short umbilical cord: A shorter cord has less slack, increasing the risk of compression.

Choice B rationale:

Maternal hypotension can cause fetal heart rate decelerations, but these typically present as late decelerations, not variable

decelerations. Late decelerations have a gradual onset, a uniform shape, and typically occur after the peak of a contraction.

Maternal hypotension can decrease placental blood flow, leading to fetal hypoxia (decreased oxygen supply). This hypoxia can

then trigger a decrease in fetal heart rate.

Choice C rationale:

The fetal sleep cycle does not typically cause variable decelerations in the fetal heart rate. During sleep, the fetal heart rate

may exhibit a decrease in baseline variability, but this is not the same as variable decelerations.

Choice D rationale:

The use of epidural anesthesia can sometimes cause a decrease in fetal heart rate variability, but it does not typically cause

variable decelerations. Epidural anesthesia can lead to maternal hypotension, which, as mentioned earlier, can cause late

decelerations.

Choice A rationale:

Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor

due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.

Key signs of umbilical cord compression include:

Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They

are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.

Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be

a sign of cord compression, as the compression can impair placental blood flow.

Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,

including cord compression.

Immediate action is crucial when umbilical cord compression is suspected. The nurse should:

Notify the provider immediately.

Change the mother's position: This can help relieve pressure on the cord. Common positions include:

Lateral positioning (lying on the side)

Trendelenburg position (lying on the back with the head tilted down)

Knee-chest position (kneeling with the chest on the bed)

Administer oxygen to the mother: This can increase fetal oxygenation.

Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid

volume), internal fetal monitoring, or cesarean delivery.

Choice B rationale:

Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not

require intervention unless it causes significant changes in the FHR or other signs of fetal distress.

Choice C rationale:

Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are

significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report

any concerns to the provider.

Choice D rationale:

Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that

occur after the peak of a contraction is "late decelerations."