Katlyn Carter

MDWF 2080 Assignment 8.2 Decelerations

October 29, 2018

Decelerations
FHR decelerations are identified as early, late, variable, or prolonged. Late decelerations and early deceleration
are gradual in onset and periodic in timing (associated with uterine contractions). Variable decelerations are
abrupt in onset and may be periodic or episodic in timing. Prolonged decelerations may be abrupt or gradual in
onset and may be periodic or episodic in timing. Decelerations are defined as recurrent if they occur with at
least 50% of uterine contractions in any 20-minute segments. All decelerations are quantitated by depths in
beats per minute (bpm) below baseline and duration in minutes and seconds.
(Mosby’s, 2017)

Early Decelerations
Definition & Characteristics

 Visually apparent, usually symmetrical, gradual decrease and return of the FHR associated with a
uterine contraction
 A gradual FHR decrease defined as one from the onset of deceleration to lowest point (nadir) of ≥30
seconds
 The decrease is calculated from the onset to the nadir of the deceleration
 The nadir of the deceleration occurs at the same time as the peak of the contraction
 Early decelerations are said to be a mirror image of the contractions.
Physiology:

 Fetal head compression resulting in cardiac slowing through a reflex vagal response
o Pressure on the fetal head.... leads to.....
o Central vagal stimulation (parasympathetic system).... leads to....
o Deceleration.... leads to....
o Recovery of FHR as pressure from the contractions decreases
Etiology:

 More likely to be nulliparous women in early active labor (head must mold through the pelvis)
 More likely if malpositioned
 May be associated with
o CPD (not common, but can happen)
o Unengaged presenting part in early labor
Classification

 NORMAL
 Not associated with fetal hypoxia, acidosis, or low APGAR scores
  Early decelerations that continue over time need to be reassessed frequently. Occasionally, early decels
have progressed into late decels and were not recognized
Considerations/Management

 None
 Consider the possibility of labor dystocia; re-examine the broad clinical picture

(Fundamentals, 2009)

Late Decelerations
Definition & Characteristics

 Visually apparent gradual decrease and return to the baseline FHR associated with uterine contraction
 A gradual decrease is defined as “from the onset of the deceleration to the FHR nadir of ≥30 seconds
 The decrease is calculated from the most recently determined portion of the baseline. The deceleration is
delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction.
 In most cases, the onset, nadir, and recovery of the deceleration after the beginning, peak and ending of
the contraction, respectfully
 The nadir may vary from almost undetectable to very obvious, usually not more than 10-20 bpm below
baseline (rarely more than 30-40 bpm)
 Gradual, smooth, delayed deceleration.
Physiology:

 Decreased uteroplacental blood flow during contraction

 Uteroplacental insufficiency
 Results in lowered fetal pO2, following peak of contraction and subsequent chemoreceptor/vagal
response
 Decreased pO2 available for diffusion (due to placental disorders/maternal health).... leads to....
 Contraction begins.... leads to .....
 Reduced O2 diffusion and decreased fetal pO2 level.... leads to....
 Activation of chemoreceptors.....
 Vagal response = late deceleration.....
 Contraction ends.....
 Increased oxygen diffusion and increased fetal pO2 level....
 Slow return to baseline
Etiology:

Chronic Conditions Acute Conditions

Conditions contributing to decreased placental  Uterine hypertonus or tachysystole
transfer of gases:  Altered maternal blood flow to the placenta
 Hypertensive disorders (maternal hypertension)
 Post term pregnancy  Reduced maternal arterial oxygen saturation
  Premature placental aging
 Reduced maternal arterial oxygen saturation
 Ongoing placental abruption
 Poor placental development/malformation
 Chronic maternal diseases such as diabetes
and collagen disease
 Vasoconstriction (ex: due to anxiety)
 Acute placental abruption
 Placenta previa with hemorrhage
 Maternal hypo/hyperventilation

Classification

 ATYPICAL (if occurring occasionally)

 ABNORMAL (if occurring >50% of contractions
Considerations/Management

 When occasional:
o Place client in lateral position
o Check maternal vital signs
o Continue observing
 When repetitive:
o Maximize fetal oxygenation
 Lateral positioning
 D/C use of oxytocin (or augmentation) if using
 Increase IV fluids
 Offer oxygen
 Prepare for delivery
o Vaginal exam to assess labor progress
o Observe for meconium
o Explain situation to client
o Prepare client for delivery, if unable to resolve (need to transfer)
(Fundamentals, 2009)

Variable Decelerations
Definition & Characteristics

 Visually apparent ABRUPT decrease

 An abrupt FHR decrease is defined as the onset of the deceleration to the beginning of the FHR nadir of
< 30 seconds
 The decrease in FHR is calculated from the onset to the nadir of the deceleration
 The decrease in FHR is ≥15 bpm, lasting for ≥15 seconds and <2 minutes in duration (from onset to
return to baseline)
 When variable decelerations are associated with uterine contractions, their onset, depth, and duration
commonly VARY with successive uterine contractions
 The most common decelerations
 Dramatic, rapid response, often giving the appearance of an icicle.
Physiology:
Umbilical cord compression: alteration in umbilical flow leads to a baroreceptor response.

 Initial compression of umbilical vein....

 Fetal hypotension (blood flow returning from placenta).....
 Transient cardio-acceleration (appears as shoulder, pre-deceleration)....
 Compression of all vessels.....
 Increased BP/stimulation of baroreceptors/reflex vagal deceleration (variable deceleration)....
 Release of umbilical artery.....
 Fetal hypotension (outflow of blood to placenta).....
 Transient cardio-acceleration (another shoulder, post-deceleration)
 Release of all vessels and return to baseline
Etiology:

 Associated with random cord compression with fetal movement (episodic)

 Commonly seen as a physiological feature in late stage or second stage
 Maternal position (cord between fetus and maternal pelvis)
 Cord around fetal body part (neck, leg, arm, etc)
 Short cord
 Knot in cord; decreased Wharton’s jelly
 Prolapsed cord (occult or obvious
 Decreased amniotic fluid (ROM of oligo)
 Malpresentation

Uncomplicated Variable Decelerations Complicated Variable Decelerations

 Initial acceleration, rapid deceleration of the
FHR to the nadir, followed by a rapid return
to the baseline FHR level with secondary
acceleration
Classification:
NORMAL: if occasional uncomplicated variable
decelerations occur
 Deceleration to <70 bpm lasting >60 seconds
 Loss of variability in the baseline FHR and in
the trough of the deceleration
 Biphasic decelerations
 Slow return to baseline
 Continuation of baseline rate at a lower level
than prior to deceleration
 Presence of fetal tachycardia or bradycardia

ATYPICAL: if repetitive (≥3) uncompleted variable Classification:

decelerations occur ABNORMAL: if repetitive, ≥3 complicated variables
occurr

Considerations/Management of Repetitive Uncomplicated & Complicated Variable Decelerations

 Alternate woman’s position to minimize/alleviate cord compression

 Vaginal exam to rule out cord prolapse and to assess labor progress
Consider:

 Lateral positioning
 D/C use of oxytocin (or augmentation) if using
 Increase IV fluids
 Offer oxygen
 Prepare for delivery
 Explain situation to client
 Prepare client for delivery, if unable to resolve (need to transfer if no improvement)
 Document
(Fundamentals, 2009)

Prolonged Decelerations
Definition & Characteristics

 Visually apparent decrease in FHR below the baseline

 decrease in FHR is ≥15 bpm below baseline, lasting >2 minutes in duration but < 10 mins (from onset
to return to baseline)
 Abrupt onset
 Usually drops at least 30 bpm from baseline
 Gradual recovery to baseline
 A prolonged deceleration lasting 10 mins or longer is a baseline change (not necessarily benign)
Physiology:

 A prolonged deceleration reflects disrupted oxygen transfer from the environment to the fetus at one or
more points along the oxygen pathway
 Depends on precipitating cause
 Associated with fetal baroreceptors and chemoreceptors reacting to profound changes in the fetal
environment
Etiology:

 Maternal hypotension
o Hypotension following epidural or spinal
o Maternal supine position
 Usually begins as a reflex autonomic response to disruption of the oxygen pathway
 Severe cord compression: ff the pathway is disrupted by cord compression, the FHR deceleration begins
as an autonomic response to fetal hypertension
o Prolapsed cord
 Uterine hypertonus
o Hypertonic contractions or tachysystole
o Uterine rupture
 Other
o Placental abruption
 o Maternal seizure, respiratory arrest, or hypoxia
o Rapid fetal descent
o Side effect of drugs or medications
o Sustained maternal Valsalva maneuver
o Results of procedure
 Vaginal exam
 Fetal blood sampling
 Attachment of internal fetal scalp electrode
Classification:

 ATYPICAL:
o If prolonged deceleration > 2 mins but <3 mins
 ABNORMAL:
o If prolonged deceleration >3 mins but <10 mins
o Usually not ominous if preceded by moderate variability and predisposing factor can be
eliminated; the placenta is usually effective in resuscitating the fetus
o Degree of concern depends on deceleration depth and duration, loss of variability, fetal
response during recovery, and frequency and progression of recurrence
Considerations/Management

 Alternate woman’s position to minimize/alleviate cord compression

 Vaginal exam to rule out cord prolapse and to assess labor progress
Consider:

 Lateral positioning
 D/C use of oxytocin (or augmentation) if using
 Increase IV fluids
 Offer oxygen
 Prepare for delivery
 Explain situation to client
 Prepare client for delivery, if unable to resolve (need to transfer if no improvement)
 Document
(Fundamentals, 2009) (Mosby’s, 2017)

References:

Lee, L., Sprague, A., Yee, J., & Ehman, W. (2009). Fundamentals of fetal health surveillance: A self-learning
manual. Vancouver, BC: Canadian Perinatal Programs Coalition.
Miller, L. A., Miller, D. A., & Cypher, R. L. (2017). Mosby's Pocket Guide to Fetal Monitoring:: A
Multidisciplinary Approach. Elsevier Health Sciences.