Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — Complications of Labor & DeliveryDetailed Explanation

Dystocia (Dysfunctional Labor) and the 4 Ps

Dystocia means difficult, prolonged, or abnormal labor. The cause is always traced back to one or more of the 4 Ps: Powers, Passageway, Passenger, and Psyche. Understanding each 'P' helps the nurse identify the problem and tailor the intervention. **Powers (Uterine Dysfunction)** refers to the strength and coordination of uterine contractions. There are two opposite patterns: 1. **Hypotonic Uterine Dysfunction** — contractions that were previously effective become weak, short, and infrequent. This usually happens in the ACTIVE phase of labor. Think of a car engine that started well but is now sputtering. Common causes include overdistension (twins, large baby, polyhydramnios) and a full urinary bladder pressing on the uterus. Management: first RULE OUT obstruction (CPD), then augment with OXYTOCIN and possibly perform an AMNIOTOMY (artificial rupture of membranes). Encourage the mother to empty her bladder regularly. 2. **Hypertonic Uterine Dysfunction** — contractions are too frequent, very painful, and UNCOORDINATED (the fundus is not dominant). They occur in the LATENT phase and do NOT dilate the cervix despite causing intense pain. The uterus never fully relaxes between contractions, which can cause fetal hypoxia. Management: REST, SEDATION (e.g., morphine), and HYDRATION. Do NOT give oxytocin — it will make the situation worse by adding more uncoordinated stimulation. **Passageway** problems refer to the bony pelvis being too small or abnormally shaped for the fetal head — this is called cephalopelvic disproportion (CPD). The nurse cannot fix CPD; it typically requires cesarean delivery. Android and platypelloid pelves are the most problematic shapes. **Passenger** problems include: - Malposition: The fetal head is in a suboptimal position, most commonly persistent occiput-posterior (OP), which causes 'back labor' — severe pain felt in the lumbar sacral area. Management: encourage hands-and-knees position or side-lying to encourage fetal rotation. - Malpresentation: The presenting part is not the fetal vertex. Examples include breech (buttocks first), brow, face, or shoulder (transverse lie) presentation. - Macrosomia: Estimated fetal weight over 4,000–4,500 g increases risk of CPD and shoulder dystocia. **Psyche** refers to the mother's emotional state. Fear, anxiety, and lack of support elevate catecholamines (adrenaline), which directly inhibit uterine contractility and increase pain perception. Therapeutic communication, the presence of a support person (doula, family), and a calm environment are nursing interventions that address the psyche.

Preterm Labor: Recognition, Tocolysis, and Fetal Lung Maturity

Preterm labor (PTL) is defined as regular uterine contractions that cause cervical change — effacement and/or dilation — occurring between **20 and 37 weeks** of gestation. It is one of the leading causes of neonatal morbidity and mortality in the Philippines, where access to neonatal intensive care is limited. The nurse's role is to recognize it early, implement measures to delay delivery, ensure fetal lung maturity is promoted, and prepare the family. **Why does it matter?** Babies born before 34 weeks have immature lungs (insufficient surfactant) and are at high risk for respiratory distress syndrome (RDS). The goal of management is to buy at least 48 hours — enough time for corticosteroids to work. **Risk Factors:** Previous preterm birth (strongest predictor), multiple gestation, uterine/cervical abnormalities, infections (especially urinary tract infection and bacterial vaginosis — a major cause in the Philippine setting), polyhydramnios, dehydration, and low socioeconomic status. **Warning Signs** (teach the patient using the mnemonic **ACUTE LABOUR**): - Regular contractions (4 or more per hour, with or without pain) - Low backache, dull and persistent - Pelvic pressure ('baby is pushing down') - Change in vaginal discharge - Fluid leakage (possible rupture of membranes) **Nursing Assessment:** Confirm gestational age, assess contraction pattern, perform fetal heart rate monitoring, check vital signs (fever suggests infection), obtain urine culture (UTI is treatable and can stop PTL), and assess cervical status. **Management:** 1. **Tocolytics** — medications that suppress uterine contractions. Used SHORT-TERM (~48 hours) to allow time for corticosteroids and transfer to a higher-level facility: - **Magnesium Sulfate (MgSO4):** First-line tocolytic in many Philippine tertiary hospitals. Also has a NEUROPROTECTIVE effect on the preterm fetal brain (reduces cerebral palsy risk when given before 32 weeks). Loading dose typically 4–6 g IV over 20 minutes, then 1–2 g/hr maintenance. **TOXICITY SIGNS** (critical to memorize — same as in preeclampsia management): Loss of deep tendon reflexes (DTRs) first, then respiratory depression (<12 breaths/min), then cardiac arrest. Monitor UO (must be ≥30 mL/hr). **Antidote: Calcium Gluconate 1 g IV.** - **Nifedipine (Calcium Channel Blocker):** Oral tocolytic, often preferred for ease of administration. Inhibits calcium entry into smooth muscle cells, relaxing the uterus. Monitor for MATERNAL HYPOTENSION. Do not give with magnesium (risk of severe hypotension and neuromuscular blockade). - **Terbutaline (Beta-2 Agonist):** 0.25 mg subcutaneously. Stimulates beta-2 receptors in the uterus causing relaxation. Side effects: maternal TACHYCARDIA (hold if HR >120 bpm), palpitations, tremors, HYPERGLYCEMIA (important in diabetic patients). Not recommended for prolonged use due to cardiac risk. - **Indomethacin (NSAID):** Used before 32 weeks. Inhibits prostaglandins (which stimulate contractions). Risk: premature closure of the DUCTUS ARTERIOSUS in the fetus. Monitor amniotic fluid (can cause oligohydramnios). 2. **Antenatal Corticosteroids for Fetal Lung Maturity:** - **Betamethasone:** 12 mg IM every 24 hours × 2 doses (48-hour course) - **Dexamethasone:** 6 mg IM every 12 hours × 4 doses (48-hour course) - Given when birth is anticipated before **34 weeks** - Maximal benefit occurs **24 hours to 7 days** after the first dose - Mechanism: stimulates fetal type II pneumocytes to produce SURFACTANT, which prevents alveolar collapse 3. **Supportive measures:** Bed rest (left lateral position to improve uteroplacental perfusion), IV hydration, identify and treat underlying infection, Group B Streptococcus (GBS) prophylaxis if positive or unknown status, and continuous fetal monitoring. 4. **Transfer:** In the Philippine setting, a woman in preterm labor at a rural health unit or lying-in clinic should be referred to a hospital with a neonatal ICU (such as a Level 3 hospital). The nurse must document thoroughly and communicate the SBAR (Situation, Background, Assessment, Recommendation) format during endorsement.

Post-Term Pregnancy: Risks and Management

Post-term pregnancy is defined as a pregnancy that extends **beyond 42 completed weeks** (294 days) from the first day of the last normal menstrual period (LNMP). It is differentiated from 'prolonged pregnancy' (some sources use these interchangeably) and from post-dates (beyond 40 weeks), which is less precise. **Why is it dangerous?** As the placenta ages beyond 42 weeks, it undergoes physiologic changes — calcification, infarction, and fibrin deposits — that REDUCE ITS ABILITY TO PERFUSE THE FETUS adequately. This is called **placental insufficiency** or **placental aging**. **Key Risks:** 1. **Oligohydramnios** — reduced amniotic fluid (amniotic fluid index [AFI] <5 cm) because the post-mature fetus produces less urine and the placenta absorbs less fluid. This creates the most dangerous condition: **cord compression**. With less fluid cushioning the cord, every fetal movement or contraction can compress it, leading to variable decelerations and, ultimately, fetal hypoxia. 2. **Meconium Aspiration Syndrome (MAS)** — the post-mature fetus, stressed by hypoxia, passes meconium in utero. If the baby inhales meconium-stained amniotic fluid, it causes severe respiratory distress after birth. In Philippine tertiary hospitals, a neonatal resuscitation team must be present at delivery when meconium is noted. 3. **Macrosomia** — continued fetal growth post-term increases birth weight, raising risk of shoulder dystocia and birth trauma. 4. **Post-maturity syndrome** — the post-mature neonate appears wrinkled (desquamating skin), has long fingernails, meconium staining of skin/nails/umbilical cord, and has lost subcutaneous fat ('old man' appearance). **Antepartum Surveillance:** Because placental function is declining, the post-term fetus must be closely monitored: - **Non-stress test (NST):** reactive NST (2 accelerations of ≥15 bpm for ≥15 seconds in 20 minutes) = reassuring - **Biophysical profile (BPP):** scores fetal breathing movements, gross body movement, tone, NST, and amniotic fluid volume; score of 8–10 is reassuring, ≤4 indicates delivery - **Amniotic fluid index (AFI):** <5 cm = oligohydramnios → deliver - **Contraction stress test (CST)** **Management:** - **Induction of labor** at 41–42 weeks depending on cervical readiness and clinical situation; cervical ripening agents (misoprostol, dinoprostone) may be used for an unfavorable cervix - At delivery: anticipate MECONIUM-STAINED fluid; have NEONATAL RESUSCITATION team ready; after delivery, if the baby is not vigorous, do NOT stimulate — suction the oropharynx before the first breath if meconium is present - Continuous electronic fetal monitoring (EFM) during labor to detect cord compression (variable decelerations) or uteroplacental insufficiency (late decelerations)

Prolapsed Umbilical Cord: The Obstetric Emergency

Umbilical cord prolapse is one of the most terrifying obstetric emergencies because it cuts off fetal oxygen supply in minutes. It occurs when the umbilical cord slips past or beside the presenting part, so the fetal weight or the presenting part COMPRESSES the cord against the cervix or vaginal wall, blocking blood flow to and from the fetus. **Types:** - **Overt/Complete prolapse:** The cord is VISIBLE at or protruding from the vaginal introitus after membrane rupture. - **Occult prolapse:** The cord is beside or behind the presenting part but NOT visible or palpable (diagnosed by sudden severe fetal bradycardia). - **Funic presentation:** The cord is BELOW the presenting part but membranes are still INTACT — the cord is palpable through the membranes. **Risk Factors** (anything that allows the cord to slip past an unengaged or absent presenting part): - Rupture of membranes before engagement (especially with cord amniotomy) - Malpresentation (breech, transverse lie) - Polyhydramnios (large gush of fluid with membranes) - Multiparity - Low birth weight / preterm (small presenting part) - Unengaged presenting part - Long umbilical cord - Multiple gestation (second twin) **Recognition:** - **Sudden, severe, prolonged fetal bradycardia** or **repetitive severe variable decelerations** — especially immediately after membrane rupture or amniotomy - Cord VISIBLE at the introitus - Cord PALPABLE on vaginal examination - ALWAYS perform a sterile vaginal exam after membrane rupture if fetal heart rate changes abruptly **PRIORITY NURSING ACTIONS — MEMORIZE THE SEQUENCE:** **STEP 1 — RELIEVE CORD COMPRESSION IMMEDIATELY:** With a sterile-gloved hand inserted into the vagina, use TWO OR THREE FINGERS to apply UPWARD PRESSURE on the presenting part — lifting it off the cord. This hand STAYS IN PLACE until the baby is delivered by emergency cesarean. Do not remove your hand — even in the elevator going to the OR. **STEP 2 — POSITION THE MOTHER:** Use a position that uses gravity to shift the fetus away from the cord: - **Knee-chest position** (best — gravity pulls the fetus away from the cord) - **Trendelenburg** (head down, feet elevated) - **Exaggerated Sims/lateral with hips elevated** These positions complement the manual hand already in place. **STEP 3 — PROTECT THE CORD (if overt prolapse):** If the cord is protruding from the vagina, wrap it in STERILE SALINE-MOISTENED GAUZE to prevent drying and vasospasm. **NEVER PUSH THE CORD BACK IN** — this causes vasospasm and further compromises blood flow. **STEP 4 — ADMINISTER OXYGEN:** Apply oxygen 8–10 L/min via face mask to maximize maternal arterial oxygen saturation and therefore fetal oxygen delivery. **STEP 5 — PREPARE FOR EMERGENCY CESAREAN:** Notify the physician, activate the emergency cesarean protocol, ensure IV access, and call the OR team. This is a Category I (immediate) cesarean — the goal is delivery within 30 minutes. **STEP 6 — CONTINUOUS FHR MONITORING:** Maintain continuous electronic fetal monitoring. Document fetal heart rate trends and nursing actions with timestamps.

Uterine Rupture: Recognition and Emergency Management

Uterine rupture is a catastrophic obstetric emergency where the uterine wall tears open. It can be **complete** (all layers, including peritoneum, are torn — fetus may spill into the abdominal cavity) or **incomplete** (partial tear, peritoneum remains intact — also called uterine dehiscence). **Causes:** - **Previous uterine scar** (most common cause) — particularly a previous **classical (vertical) uterine incision** from a prior cesarean section. The LOW TRANSVERSE scar is much less likely to rupture. - Excessive or prolonged oxytocin stimulation (tachysystole) - Grand multiparity (weakened uterine muscle) - Obstructed labor (dystocia) with continued contractions - Uterine trauma (blunt abdominal trauma, obstetric maneuvers) - Uterine anomalies **Clinical Manifestations — The 'RUPTURE' Pattern:** 1. **Sudden, sharp, tearing abdominal pain** — often described as 'something popped' or 'something tore inside.' With an epidural in place, the woman may complain of sudden breakthrough pain. 2. **Abrupt CESSATION of contractions** — the uterus loses its integrity and stops contracting. This is paradoxical: the woman who was having strong contractions suddenly feels 'relief' — but this is a BAD sign. 3. **Loss of fetal station** — the presenting part that was at a certain station may suddenly move UPWARD as the fetus slips into the abdominal cavity. 4. **Abnormal or absent fetal heart rate** — prolonged bradycardia, severe variable decelerations, or complete loss of FHR signal. 5. **Signs of hypovolemic shock:** - Rapid, weak, thready pulse - Falling blood pressure - Pallor, cold clammy skin - Increasing abdominal distension - Falling urinary output 6. **Palpable fetal parts outside the uterus** (in complete rupture) — the fetus can be palpated directly under the abdominal wall. 7. **Visible hematuria** if the bladder is involved. **Nursing/Medical Management — Emergency Protocol:** 1. **CALL FOR HELP / ACTIVATE CODE** — notify physician and surgical team immediately 2. **Prepare for EMERGENCY LAPAROTOMY** — surgical delivery and repair or hysterectomy 3. **Treat hypovolemic shock aggressively:** - Insert large-bore IV lines (16 G or larger), two lines if possible - Infuse IV fluid (Normal Saline or Lactated Ringer's) - Transfuse blood products as ordered (type and crossmatch) - Apply oxygen at 8–10 L/min - Monitor vital signs every 5 minutes - Insert Foley catheter and monitor hourly urine output 4. **STOP OXYTOCIN immediately** if infusing 5. **Continuous EFM** — document the deteriorating pattern 6. **NPO** — surgery is imminent 7. **Emotional support** — communicate clearly and calmly to the family **Prevention:** - VBAC (vaginal birth after cesarean) with a LOW TRANSVERSE uterine scar can be attempted (TOLAC — trial of labor after cesarean) — these women should be closely monitored for rupture - Women with a CLASSICAL (vertical) uterine incision should have a SCHEDULED CESAREAN before labor begins — labor is CONTRAINDICATED - Cautious use of oxytocin — respect the maximum dose and monitor for tachysystole - NEVER apply fundal pressure (Kristeller maneuver) during dystocia — this can cause rupture

Cesarean Birth: Indications, Types, and Nursing Care

Cesarean section (C-section) is the surgical delivery of a baby through incisions in the mother's abdomen (laparotomy) and uterus (hysterotomy). In the Philippines, cesarean rates have been rising in both public (PhilHealth-covered) and private hospitals, making comprehensive perioperative nursing care a critical skill. **INDICATIONS for Cesarean (when vaginal delivery is impossible, dangerous, or contraindicated):** - Cephalopelvic disproportion (CPD) - Fetal distress (non-reassuring FHR not corrected by intrauterine resuscitation) - Malpresentation (breech, transverse lie) - Placenta previa (complete) - Placental abruption with fetal compromise - Active genital herpes (HSV) infection — to prevent neonatal transmission - Previous classical uterine incision - Failed induction of labor - Prolapsed umbilical cord (when vaginal delivery is not imminent) - HIV with high viral load - Certain cases of twins (depending on presentation) **TYPES OF UTERINE INCISIONS — HIGH-YIELD NLE POINT:** 1. **Low Transverse Incision (Kerr incision, Pfannenstiel):** Made in the lower uterine segment, horizontally. This is the PREFERRED and MOST COMMON type because: - Less blood loss - Easier to repair - Lower risk of rupture in future pregnancies - **Allows TOLAC (Trial of Labor After Cesarean)/VBAC in future pregnancies** 2. **Classical (Vertical/Midline) Incision:** Made vertically through the upper uterine body. Used in emergencies, placenta previa covering the lower segment, or when the lower segment is not well-formed (very preterm). - More blood loss - Higher rupture risk in future pregnancy - **FUTURE LABOR IS CONTRAINDICATED — scheduled repeat cesarean required** **PRE-OPERATIVE NURSING CARE:** 1. Obtain INFORMED CONSENT (signed, witnessed — essential under RA 9173 and DOH guidelines) 2. NPO status (nothing by mouth) — typically 6–8 hours for solids, 2 hours for clear liquids 3. Administer ANTACID or H2 BLOCKER (e.g., ranitidine) — to reduce gastric acidity and aspiration risk under anesthesia (Mendelson's syndrome prevention) 4. Insert INDWELLING URINARY CATHETER (Foley) — to decompress the bladder and monitor output intraoperatively 5. Insert large-bore IV access (18 G minimum) 6. Administer pre-operative antibiotics as ordered (prophylaxis against surgical site infection) 7. Prepare the abdomen (per hospital protocol) 8. Complete preoperative checklist: remove nail polish, dentures, jewelry 9. Provide emotional support and address the mother's fears 10. Administer anesthesia pre-medications as ordered **POST-OPERATIVE NURSING CARE:** 1. **Monitor fundus and lochia:** Assess uterine tone every 15 minutes for the first hour — POST-PARTUM HEMORRHAGE is the priority complication. The fundus should be firm, at midline, at the level of the umbilicus. 2. **Vital signs:** Every 15 min for 1 hour, then per protocol as stable 3. **Pain management:** Administer analgesics per order; patient-controlled analgesia (PCA) if available; assess pain using VAS/NRS 4. **IV fluids:** Maintain until oral intake is established 5. **Foley catheter:** Keep for 12–24 hours post-op; monitor hourly urine output (≥30 mL/hr) 6. **Incision site:** Assess for signs of infection, dehiscence, or hematoma 7. **Bowel function:** Expect absent bowel sounds initially (paralytic ileus is a risk); progress to clear liquids then diet as bowel sounds return 8. **Early ambulation:** Encourage within 6–24 hours to prevent DVT, promote bowel function, and speed recovery 9. **Leg exercises:** Ankle pumps and calf compression while on bed rest — thromboembolism prevention 10. **Breastfeeding support:** C-section does not preclude breastfeeding; assist with positioning (football hold avoids incision pressure) 11. **Deep breathing and coughing exercises:** Prevent atelectasis (teach splinting the incision with a pillow) 12. **Emotional support:** C-section may create feelings of loss or failure — validate feelings, encourage bonding 13. **Discharge education:** Wound care, activity restrictions, warning signs of infection, when to return to the OB clinic

Other Obstetric Emergencies: Shoulder Dystocia and Amniotic Fluid Embolism

**SHOULDER DYSTOCIA** Shoulder dystocia occurs when the fetal head delivers but the ANTERIOR SHOULDER cannot pass under or around the maternal symphysis pubis. It is an emergency because once the head is out, the baby's neck is compressed and breathing is impossible — you have minutes to deliver the body. **Recognition — The 'Turtle Sign':** After the head delivers, it RETRACTS back against the perineum ('the head seems to go back in') — like a turtle pulling its head back into its shell. This is pathognomonic for shoulder dystocia. **Risk Factors:** Macrosomia (most significant), maternal diabetes (large baby), post-term pregnancy, obese mother, short maternal stature, previous shoulder dystocia, assisted vaginal delivery (forceps, vacuum). **Management — Memorize the HELPERR Mnemonic:** - **H** — Call for **Help** (extra nurses, physician, pediatrics) - **E** — Evaluate for **Episiotomy** (creates more space, though it doesn't directly help with bony dystocia) - **L** — Leg Hyperflexion (**McRoberts Maneuver**) — the thighs are sharply flexed onto the abdomen; this ROTATES the symphysis pubis upward and flattens the lumbar lordosis, increasing the functional diameter of the pelvis by up to 22%. This is the FIRST and MOST EFFECTIVE maneuver. - **P** — **Suprapubic Pressure** — an assistant applies DOWNWARD and LATERAL pressure directly on the maternal suprapubic area (NOT the fundus) to dislodge the impacted anterior shoulder. **NEVER apply fundal pressure — it worsens impaction.** - **E** — **Enter** maneuvers (internal rotational maneuvers — Rubin II, Woods Screw, Reverse Woods/Barnum) - **R** — Remove the posterior arm - **R** — **Roll the patient** (Gaskin maneuver — hands-and-knees position) **Complications:** - **Neonatal:** Brachial plexus injury (Erb's palsy — affects C5-C6, causing the classic 'waiter's tip' position), clavicle fracture, humerus fracture, hypoxic brain injury - **Maternal:** Postpartum hemorrhage, 3rd/4th degree lacerations, vaginal/cervical tears **KEY NLE POINT:** McRoberts Maneuver + Suprapubic Pressure are the FIRST two actions (after calling for help). **NEVER apply fundal pressure.** --- **AMNIOTIC FLUID EMBOLISM (AFE)** AFE is an obstetric catastrophe where amniotic fluid (containing fetal cells, hair, vernix, meconium) enters the MATERNAL BLOODSTREAM through tears in the uterus, placenta, or cervical veins. The amniotic fluid triggers an anaphylactoid-like reaction — massive pulmonary vasoconstriction, left heart failure, and DIC (disseminated intravascular coagulation). **Recognition — Classic Triad:** 1. **Sudden, severe RESPIRATORY DISTRESS** — acute hypoxia, dyspnea, cyanosis 2. **CARDIOVASCULAR COLLAPSE** — hypotension, cardiac arrest 3. **DIC** — coagulopathy (bleeding from IV sites, gums, vagina; oozing from everywhere) Other signs: altered consciousness, seizures, fetal distress (severe bradycardia) **Timing:** AFE most commonly occurs during LABOR or immediately AFTER delivery. Risk factors: advanced maternal age, multiparity, rapid/forceful labor, amnioinfusion, cesarean. **Management — Supportive, Immediate:** 1. **Call a code/activate emergency response** immediately 2. **CPR** if cardiac arrest occurs — position in LEFT LATERAL TILT (or manual uterine displacement) to relieve aortocaval compression 3. **High-flow Oxygen** — 100% via non-rebreather mask or intubation/mechanical ventilation 4. **IV access** — large-bore bilateral IVs for massive fluid resuscitation and blood products 5. **Treat DIC** — fresh frozen plasma (FFP), platelets, cryoprecipitate, packed red blood cells 6. **Vasopressors** — dopamine or norepinephrine for refractory hypotension 7. **DELIVER THE BABY** — if arrest occurs before delivery, perimortem cesarean within 5 minutes improves maternal and fetal survival 8. **Continuous EFM and vital signs** **Prognosis:** AFE has a mortality rate of up to 80% — there is no specific antidote; management is entirely supportive.

Fetal Heart Rate Monitoring: Interpreting Patterns in Complicated Labor

Electronic fetal monitoring (EFM) is the primary tool for detecting fetal compromise during labor. Understanding FHR patterns allows the nurse to recognize early deterioration and intervene before irreversible fetal hypoxia occurs. **NORMAL FETAL HEART RATE:** - Baseline: **110–160 bpm** (bradycardia <110; tachycardia >160) - **Moderate variability:** 6–25 bpm fluctuation from baseline — the MOST REASSURING sign of fetal well-being (indicates an intact, oxygenated fetal nervous system) - **Accelerations:** Abrupt increases in FHR ≥15 bpm above baseline lasting ≥15 seconds — REASSURING (reactivity indicates fetal well-being; basis of the NST) - Absence of late or variable decelerations **TYPES OF DECELERATIONS — The Most High-Yield NLE Topic:** 1. **EARLY DECELERATIONS:** - Shape: Uniform, U-shaped, mirror image of the contraction - Timing: Onset and recovery COINCIDE with the contraction (nadir at the peak of contraction) - Cause: FETAL HEAD COMPRESSION — pressure on the fetal head during contraction stimulates vagal tone - Significance: **BENIGN — no intervention needed** - Analogy: Think of it as the fetus 'pressing pause' in sync with the contraction 2. **VARIABLE DECELERATIONS:** - Shape: Abrupt, V-shaped or U-shaped, vary in timing, duration, and depth from one contraction to the next - Timing: Variable — may occur before, during, or after contractions; NOT consistently related to contraction timing - Cause: **CORD COMPRESSION** — umbilical cord is compressed by the presenting part, fetal body, or decreased amniotic fluid - Significance: **CONCERNING when severe (below 70 bpm for >60 seconds, loss of variability)** — requires REPOSITIONING of the mother to relieve cord compression - Moderate variable decelerations that recover quickly may be tolerated; SEVERE = escalate 3. **LATE DECELERATIONS:** - Shape: Smooth, uniform, gradual curve - Timing: Onset AFTER the contraction peaks; nadir after the contraction peak; recovery AFTER contraction ends — always DELAYED relative to the contraction - Cause: **UTEROPLACENTAL INSUFFICIENCY (UPI)** — the placenta cannot adequately oxygenate the fetus during the stress of contractions; fetal hypoxia triggers chemoreceptor-mediated vagal response - Significance: **OMINOUS — ALWAYS require intervention.** Even one late deceleration is clinically significant; repeated late decelerations with loss of variability = Category III = DELIVERY - Associated with: Oxytocin overstimulation, placental abruption, preeclampsia, maternal hypotension, post-term pregnancy **INTRAUTERINE RESUSCITATION BUNDLE (for non-reassuring FHR):** Remember: **'STOP LOOK ACT'** or the classic sequence: 1. **STOP OXYTOCIN** (remove the uterine stimulus) 2. **REPOSITION to LEFT LATERAL** (relieve aortocaval compression, improve uteroplacental perfusion) 3. **IV FLUID BOLUS** (increase maternal blood volume and placental perfusion) 4. **APPLY OXYGEN** (8–10 L/min via non-rebreather mask) 5. **NOTIFY THE PHYSICIAN** (report the pattern, document, prepare for possible delivery) 6. If cord prolapse suspected: manual elevation of presenting part 7. **TERBUTALINE** may be ordered to relax the uterus (for tachysystole) **FHR CATEGORIES (NICHD Classification):** - **Category I:** Normal — routine monitoring - **Category II:** Indeterminate — requires increased surveillance; most FHR patterns fall here - **Category III:** Abnormal (sinusoidal pattern or absent variability + late/variable decelerations/bradycardia) — REQUIRES PROMPT EVALUATION AND DELIVERY

Key clues: LATENT phase (1 cm, 30% effaced), contractions are frequent and painful but NOT producing cervical change, uncoordinated with no fundal dominance = hypertonic pattern. The pain is REAL but unproductive. Oxytocin is contraindicated — it would add more uncoordinated stimulation to an already hypertonic uterus, worsening maternal pain and fetal compromise. Sedation and rest allow the uterus to return to a coordinated, effective pattern. This is a classic NLE differentiator: knowing WHICH type of dysfunction presents in WHICH phase.

This tests medication safety for terbutaline AND clinical reasoning about preterm labor causes. Under RA 9173, the nurse has the responsibility to assess the patient BEFORE administering medication and to withhold a medication that is unsafe based on assessment findings. The betamethasone is safe to give (no contraindication). The UTI finding (3+ leukocytes) is clinically relevant — treating the underlying infection may help stop PTL — and must be communicated to the physician.

The unengaged presenting part at the time of amniotomy is the root cause — the cord slipped through with the rush of amniotic fluid. This is WHY engagement must be confirmed before amniotomy. The FIRST and most critical action is manually lifting the presenting part off the cord — this is a direct, life-saving intervention that only the nurse can initiate immediately. Calling the physician happens SIMULTANEOUSLY (have another staff member call), not before acting. This scenario is extremely high-yield for the NLE because it tests sequencing of emergency interventions.

The 'turtle sign' (head retraction) is the hallmark of shoulder dystocia. McRoberts + suprapubic pressure resolves the majority of cases. The nurse's role is to: position the patient quickly, assist the second person with suprapubic pressure, call for help, and document. Fundal pressure is ABSOLUTELY CONTRAINDICATED — it drives the anterior shoulder further into the symphysis, worsening impaction. Knowing both what TO DO and what NOT TO DO is essential for NLE success. The previous low transverse cesarean is relevant history but does not change the immediate management — the baby must be delivered now.

A boggy postpartum uterus is UTERINE ATONY — the leading cause of postpartum hemorrhage. The vital sign changes (dropping BP, rising HR) indicate the patient is moving into hypovolemic shock. This is a priority-setting question requiring application of the ABCs (circulation is compromised) and Maslow's physiologic needs hierarchy. Fundal massage is the first independent nursing action to stop bleeding. Oxytocin (the uterotonic of choice) requires a physician's order, but the nurse can initiate IV fluids and oxygen independently while calling the physician.