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MONITOR CORNERA CASE STUDY BY SHARON RECTOR, RNC-OB, C-EFM, MSNPRESENTATIONMs. L is a 20 year old, G3P1011 who presented to labor anddelivery at 39 weeks and 3 days gestation with a spontaneouslyruptured bow of water, leaking green tinged amniotic fluid.Contractions on admission were mild and irregular occurringabout every 4-8 minutes. The fetal heart rate (FHR) baselinewas 140 bpm, with moderate variability, accelerationspresent and no decelerations (Category I). Her cervical examon admission was 2 cm, 50% effaced, -3 station, moderateconsistency and midposition with a cephalic presentation. Shewas admitted for expectant management of labor.BACKGROUNDMs. L was previously diagnosed with Bipolar II Disorder forwhich she had inconsistently taken her prescribed medications.She had a history of marijuana use with a positive urine drugscreen for marijuana during the pregnancy. She was alsodiagnosed with GBS bacteriuria in the first trimester.Her labor progressed spontaneously, and she received anepidural for pain management. She was given penicillin G 5million units IV followed by 2.5 million units IV every 4 hours.Approximately 1 hour after the epidural was placed strip #1was observed. Her cervical exam was 4 cm, 50% effaced, -2station, soft and midposition. Her blood pressure was 116/62to 120/70 and her heart rate was 62-68 bpm. Strip #2 occurredapproximately 15 minutes later. How would you interpretthese tracings? What interventions are indicated?INTERPRETATION AND DISCUSSIONIn strip #1 the baseline FHR is 145 bpm, the variability ismoderate, there are no accelerations and there are latedecelerations (Category II). A late deceleration is defined asa gradual (onset to nadir ≥ 30 seconds) decrease of the FHRfrom the baseline associated with a uterine contraction. Inmost cases the onset, nadir and recovery of the decelerationoccur after the beginning, peak and ending of the contraction,respectively. A late deceleration reflects disruption ofmaternal-fetal oxygen transfer from the environment tothe fetus resulting in transient fetal hypoxemia (Tucker,Miller & Miller, 2009). Interventions that will maximize fetaloxygenation are indicated and might include maternal positionchange, intravenous fluid administration, reduction of uterineactivity and oxygen administration. If the disruption of oxygentransfer is recurrent or sustained, it may progress to the stageof metabolic acidemia. The FHR during the decelerations isirregular, ranging from 80-90 bpm to 150-155 bpm, similarto the appearance of marked variability. Variability is aTRACING 1VOL. 27 NO. 1 | MARCH 2013
characteristic of the FHR baseline, and as such it shouldnot be used to describe decelerations. According to Tucker,Miller & Miller (2009) the appearance of variability duringa deceleration has not been studied, and they discourageassigning undue significance to its occurrence. The moderatebaseline variability in this strip is highly predictive of theabsence of fetal metabolic acidemia.In strip #2 the baseline FHR is 155 bpm, the variability isminimal, there is one acceleration near the end of the stripand there are recurrent late decelerations (Category II). Somemight question the presence of late decelerations. Theyare subtle, the onset to nadir is about 25 seconds and thetiming appears to be delayed. This doesn’t completely fit thedefinition of a late deceleration, but these characteristicsdon’t completely fit any of the definitions of the four typesof decelerations. What do you do when a decelerationpattern doesn’t quite fit any of the definitions perfectly?Use your clinical judgment to most accurately label thedeceleration pattern, continue appropriate interventions andobserve closely. It is imperative that this type of tracing bereviewed and discussed by all members of the care team.Communication among care providers is paramount especiallywhen there may be variation in the assessment, interpretationand plan of care.OUTCOMEInterventions in this situation included lateral positioning, IVfluid bolus and the administration of oxygen. Within about30 minutes the FHR returned to a baseline of 140 bpm,with moderate variability, occasional accelerations and noadditional late decelerations. The contractions became moreirregular with minimal change in her cervical exam.Oxytocin was administered and approximately 5 hours afterinitiation Ms. L was completely dilated. Shortly thereafter ababy boy was delivered vaginally with Apgar scores of 8 and9 at 1 and 5 minutes respectively. He weighed 4200 grams.Mom and baby had a normal postpartum course and weredischarged on day 2. ●REFERENCETucker, S.M., Miller, L.A., & Miller D.A. (2009). Fetal monitoring: A multidisciplinaryapproach (6th ed.). St. Louis, MO: Mosby Elsevier.ABOUT THE AUTHORSharon Rector is an Education Consultant specializing in perinatal nursing at SSMHealth Care in St. Louis.TRACING 2THE PERINATAL TIMES | 7
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