Exam 2 — Labor and birth, fetal monitoring, analgesiaWeek 7
📚 Reading: ch. 16 — Exam 2, confirmed by the recording
Lining up with the contraction = normal. Lagging behind = the placenta is failing.
💡 The one idea
Read the deceleration by its shape and its timing against the contraction. That is the
whole skill. VEAL CHOP tells you what each one means.
V E A L
C H O P
Means
Do
Variable decel
Cord compression
Cord squeezed
Reposition the mother
Early decel
Head compression
Normal — mirrors contraction
Nothing. Document
Accelerations
Oxygenation OK
Reassuring
Nothing. Good sign
Late decel
Placental insufficiency
Worst one — poor perfusion
Full intervention
🖼️ Fetal heart rate decelerations.Swipe it sideways if it is cut off, or tap to open it full size.
🚨 Late decelerations — the intervention order
1Turn to the LEFT side
2Stop oxytocin if running
3Oxygen 8–10 L by non-rebreather
4Increase IV fluids
5Notify provider; prepare for delivery
Why the left side? It lifts the uterus off the inferior vena cava,
which restores venous return, cardiac output and therefore placental blood flow.
Left side is the answer to a huge number of maternity questions.
💉 Epidural — what the nurse does
Before: IV fluid bolus to prevent the drop in blood pressure, and empty the bladder.
After: blood pressure every 5 minutes at first. The commonest complication is
maternal hypotension, which causes fetal bradycardia.
If BP drops: left side, IV fluids, oxygen, notify. Ephedrine if ordered.
Assess bladder regularly - she cannot feel it full, and a distended bladder stalls labor.
⭐ High-yield — what the exam actually asks
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Reassuring FHR: baseline 110–160 bpm with moderate variability of 6–25 bpm.
VEAL CHOP: Variable → Cord compression · Early → Head compression · Accelerations → OK · Late → Placental insufficiency.
Early decelerations = head compression. Benign and normal in labor — verify with a cervical exam. No oxygen, no repositioning, no cesarean.
Late decelerations = uteroplacental insufficiency. Her bundle: left lateral → oxygen by nonrebreather ~10 L/min → STOP the Pitocin → IV fluid bolus → notify the provider. Never increase oxytocin. Documentation alone is not enough.
Epidural sequence: IV fluid bolus first to prevent hypotension → frequent maternal BP and FHR → keep her off her back → she stays in bed.
Post-epidural priority is maternal BP and fetal heart rate — maternal hypotension causes fetal bradycardia. BP 88/50 at 30 minutes = act now: reposition, IV fluids, notify. Mild itching and pelvic pressure are expected.
No ambulation immediately after an epidural — motor block, fall risk.
IV narcotics belong in the latent phase — too close to birth they cause neonatal respiratory depression. Local infiltration is for episiotomy or laceration repair.
📕 From your ATI review book
Covered by ch. 13 & 12.
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Tachycardia and bradycardia require 10 minutes or more at the abnormal rate — not a passing dip.
Category I needs ALL of: baseline 110–160, moderate variability, no late or variable decelerations. Category III is a sinusoidal pattern, or absent variability plus recurrent lates, recurrent variables, or bradycardia. Everything else is Category II.
Late deceleration response in order: side-lying first → stop the oxytocin → open the IV → notify → oxygen if maternal hypoxia → prepare for expedited birth.
Variable deceleration response: reposition (side to side or knee-chest) → stop oxytocin → vaginal exam to rule out prolapse → prepare for amnioinfusion.
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Amnioinfusion treats VARIABLE decelerations from cord compression and oligohydramnios. Membranes must already be ruptured. Weigh pads to confirm return and prevent overdistention.
Uterine tachysystole = more than 5 contractions in 10 min → terbutaline 0.25 mg subcut.
Internal monitoring is the only way to measure true contraction intensity — needs ruptured membranes, 2–3 cm, and a descended presenting part.
Epidural: IV fluid bolus FIRST. If hypotension develops — reposition laterally, increase fluids, oxygen, and have ephedrine ready.
Have naloxone available with systemic opioids. Butorphanol and nalbuphine cause less respiratory depression. Confirm labor is established first or you slow it.
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Spinal block → higher rate of postdural puncture headache; definitive treatment is an autologous blood patch.
Pudendal block goes in 10–20 min before birth for perineal anesthesia, with no systemic maternal or fetal effect.
Hyperventilation from patterned breathing → tingling fingers, lightheaded. Breathe into cupped hands or a paper bag — not oxygen.
Effleurage is abdominal and will not touch OP back pain — that needs sacral counterpressure and hands-and-knees.
Before general anesthesia: NPO confirmed, oral antacid, famotidine, metoclopramide, hip wedge. Afterward expect uterine relaxation → watch for hemorrhage.
📚 From your Maternal & Child textbook
Pillitteri, Maternal and Child Health Nursing — ch. 15–16 (labor, and comfort during labor).
Fetal heart tones are heard best over the fetal back, which is why Leopold's manoeuvres come before placing the monitor.
⚠️ Exam traps
Absent variability is the finding that should scare you, even with a normal baseline. Moderate variability is reassuring.
Early vs late decel is the single highest-yield discrimination in this course. Early → do nothing but confirm. Late → act.
🧠 Mind maps 1
Built from this page's own content — the same four questions every time, so the shape is familiar before the topic is.
Fetal Monitoring & Comfort in Labor
🎯 What the strip shows
Baseline 110–160 bpm between contractions.
Variability — the normal jitter. Moderate (6–25 bpm) is the single best sign of good oxygenation.
Accelerations — reassuring, and they mean the same thing as moderate variability.
Decelerations — classified by their timing against the contraction, not their depth.
👀 VEAL CHOP
Variable → Cord compression. Abrupt, any time.
Early → Head compression. Mirrors the contraction. Benign.
Accelerations → Okay.
Late → Placental insufficiency. Begins after the contraction starts and recovers after it ends. The dangerous one.
🧪 What it means
Early is in step with the contraction; late lags behind it. Shape tells you the cause.
Lates are shallow and unimpressive, which is exactly why they get missed.
Absent variability is worrying even on a flat, peaceful-looking strip. Flat is not calm.
Category I is reassuring, Category III requires immediate action.
🩺 Intrauterine resuscitation, in order
Reposition to the side — first because it is fastest and free.
Stop the oxytocin if it is running.
IV fluid bolus to raise placental perfusion.
Oxygen by non-rebreather.
Notify the provider. The exam offers all five and asks which is first.
🎥 Lecture recordings 2
Tap a card to open that recording in Google Drive. The same list lives in the lecture library.
ATI Active Learning Template — System DisorderPain Management
Filled from ATI chapter 12, row by row from that chapter’s own sections — 12 of 12 rows have content.
9 rows came from outside your ATI chapter — 5 cite a source, 4 are built from this page’s own notes. Each one is labeled.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
This chapter reviews the sources and phases of labor pain, the gate-control theory behind nonpharmacological comfort measures, and pharmacological options from analgesics to regional and general anesthesia, plus nursing safety priorities for each.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Childbirth education and a known support person reduce reported pain and the need for analgesia.
Offer non-pharmacological methods first and continuously, not only until the epidural.
Hydrotherapy, position change, counter-pressure, massage, breathing and heat all have evidence behind them.
Ask what she wants before labor and again in labor — and honor a change of mind without comment.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Not in your ATI chapter — filled from StatPearls, 2024.
Absolute contraindications to epidural anesthesia include patient refusal, infection at the injection site, and increased intracranial pressure.
Uncorrected coagulopathy or therapeutic anticoagulation are relative contraindications to epidural placement.
Hemodynamic instability and inability to hold the required positioning are additional relative contraindications.
StatPearls (NCBI Bookshelf) · Epidural Anesthesia · open the source →
Assessment — Expected Findings
From this module — built from the notes above on this page, not a section of the ATI chapter.
First stage pain is visceral — dull, diffuse, felt over the lower abdomen and back.
Second stage pain is somatic — sharp, well localized to the perineum.
After an epidural, expect warmth and heaviness in the legs and loss of the urge to void.
Hypotension after an epidural is expected enough to plan for, but never accepted — fluid, left-lateral position, and notify anesthesia.
Expect maternal pruritus and occasional nausea with epidural opioids.
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
From this module — built from the notes above on this page, not a section of the ATI chapter.
Platelet count before a regional block — thrombocytopenia is a contraindication.
Coagulation studies where clotting is in question.
No routine labs for non-pharmacological methods.
Blood glucose if she has been fasting for a long labor.
Diagnostic Procedures
From this module — built from the notes above on this page, not a section of the ATI chapter.
Pain assessment is the procedure — a numeric scale, plus what she looks like between contractions.
Continuous fetal monitoring after regional analgesia, because of the hypotension risk.
Blood pressure every 5 minutes for the first 15–20 minutes after an epidural is dosed.
Assess bladder fullness regularly — she will not feel it.
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Epidural/spinal opioids (e.g., fentanyl, sufentanil) give analgesia while preserving sensation and the ability to bear down
Epidural block: bupivacaine plus an opioid at the L4-L5 level blocks pain from umbilicus to thighs but may spare pressure sensation
Give an IV fluid bolus before/with epidural placement to offset hypotension; position the client side-lying
Watch epidural clients for hypotension, fetal bradycardia, and respiratory depression; keep O2 and suction ready
Treat epidural hypotension with lateral positioning, increased IV fluid rate, oxygen, and a vasopressor such as ephedrine
Check bladder for distention and catheterize as needed; confirm leg sensation/motor return before the client stands
Spinal block numbs nipples to feet, is used for cesarean birth or late second stage, and is not used for ongoing labor
Spinal block risk: headache from CSF leak; an autologous blood patch is the most effective relief
Systemic opioids (meperidine, fentanyl, butorphanol, nalbuphine) are IV-preferred and given during early active labor
Medications
Not in your ATI chapter — filled from StatPearls, 2024.
Labor epidurals typically combine a local anesthetic, such as bupivacaine or ropivacaine, with an opioid like fentanyl or sufentanil.
A 3 mL test dose of 1.5% lidocaine with 1:200,000 epinephrine is commonly given before the full epidural dose.
StatPearls (NCBI Bookshelf) · Epidural Anesthesia · open the source →
Therapeutic Procedures
Not in your ATI chapter — filled from StatPearls, 2024.
Standard American Society of Anesthesiologists monitoring equipment is applied before epidural placement begins.
The patient is positioned in spinal flexion, either sitting or side-lying, to open the spaces between vertebrae for needle placement.
Intravenous fluids are typically given before epidural placement to help prevent hypotensive episodes.
StatPearls (NCBI Bookshelf) · Epidural Anesthesia · open the source →
💬 Around the patientClient Education · Interprofessional Care
Client Education
From this module — built from the notes above on this page, not a section of the ATI chapter.
Opioids and sedatives cause drowsiness - client should request help with ambulation
Sedatives are avoided when birth is imminent but can ease anxiety and promote sleep in early/latent labor
Do not give sedatives if birth is expected within 12-24 hr due to neonatal respiratory depression risk
Nitrous oxide is self-administered, intermittent, and reduces (not eliminates) pain; onset and clearance are rapid with no tissue buildup
Metoclopramide controls nausea/vomiting as an opioid adjunct but does not relieve pain; can cause dry mouth and drowsiness
Interprofessional Care
Not in your ATI chapter — filled from StatPearls, 2024.
Epidural catheter placement requires a qualified clinician, typically an anesthesiologist or a nurse anesthetist.
Safe epidural use relies on an interprofessional team of anesthesia clinicians, specialty-trained nurses, and pharmacists working together.
StatPearls (NCBI Bookshelf) · Epidural Anesthesia · open the source →
⚠️ What goes wrongComplications
Complications
Not in your ATI chapter — filled from StatPearls, 2024.
Hypotension is a common complication of epidural anesthesia, one reason IV fluids are given beforehand.
Postdural puncture headache can occur if the dura is unintentionally punctured during placement.
Accidental intrathecal injection can cause total spinal anesthesia, a rare but serious complication.
Epidural hematoma, abscess, and nerve injury are rare but serious complications requiring prompt recognition.
StatPearls (NCBI Bookshelf) · Epidural Anesthesia · open the source →
📋 Fetal Assessment During Labor6 parts
ATI Active Learning Template — System DisorderFetal Assessment During Labor
Filled from ATI chapter 13, row by row from that chapter’s own sections — 12 of 12 rows have content.
9 rows came from outside your ATI chapter — 5 cite a source, 4 are built from this page’s own notes. Each one is labeled.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Covers assessing fetal well-being during labor using Leopold maneuvers to palpate lie, presentation, and descent, plus fetal heart rate and uterine contraction monitoring methods and how to interpret the tracings.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Explain what the monitor is showing — an unexplained tracing is frightening and the fear is avoidable.
Intermittent auscultation is appropriate in low-risk labor and allows more movement.
Encourage position changes; left lateral maximizes placental perfusion.
Maintain hydration and avoid the supine position.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Not in your ATI chapter — filled from StatPearls, 2024.
Roughly 85% of US births now involve continuous electronic monitoring rather than intermittent listening alone.
Maternal factors favoring continuous monitoring include chronic hypertension, diabetes, and obesity.
Fetal and obstetric factors favoring continuous monitoring include growth restriction, decreased fetal movement, multiple gestation, and postterm pregnancy.
StatPearls (NCBI Bookshelf) · Fetal Heart Rate Tracing: Assessment and Clinical Interpretation · open the source →
Assessment — Expected Findings
Not in your ATI chapter — filled from StatPearls, 2024.
A normal fetal heart rate baseline falls between 110 and 160 beats per minute.
Moderate variability, an amplitude range of 6 to 25 bpm, is considered reassuring; minimal variability is 5 bpm or less.
An acceleration at or after 32 weeks peaks at least 15 bpm above baseline and lasts at least 15 seconds.
Variable decelerations drop abruptly, with onset to lowest point in less than 30 seconds, a decrease of at least 15 bpm lasting at least 15 seconds.
StatPearls (NCBI Bookshelf) · Fetal Heart Rate Tracing: Assessment and Clinical Interpretation · open the source →
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
From this module — built from the notes above on this page, not a section of the ATI chapter.
No routine labs — assessment is the tracing itself.
Cord blood gases after birth when the tracing was concerning, to document acid-base status.
Maternal CBC and type and screen if operative birth becomes likely.
Lactate or glucose if maternal exhaustion or ketosis is suspected.
Diagnostic Procedures
Not in your ATI chapter — filled from StatPearls, 2024.
A Category I tracing is the reassuring pattern: a baseline within normal limits, moderate variability, and an absence of late or variable dips.
Category II tracings are indeterminate, meaning they meet criteria for neither Category I nor Category III.
Category III tracings are abnormal, showing absent variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern.
StatPearls (NCBI Bookshelf) · Fetal Heart Rate Tracing: Assessment and Clinical Interpretation · open the source →
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Leopold maneuvers: four external palpations to find fetal lie, presentation, descent, and back position.
Category I tracing = normal baseline and moderate variability with no late/variable decels; Category III = absent variability plus recurrent late/variable decels or a sinusoidal pattern.
Uterine tachysystole = more than 5 contractions in 10 min, which can reduce fetal oxygenation.
External monitoring is noninvasive and needs no rupture or dilation, but can't quantify contraction intensity.
Internal monitoring needs ruptured membranes and cervix dilated at least 2 to 3 cm; gives accurate variability and contraction strength.
Medications
From this module — built from the notes above on this page, not a section of the ATI chapter.
The first response to a non-reassuring tracing is usually to stop the oxytocin, not to give something.
IV fluid bolus to improve placental perfusion.
Oxygen by non-rebreather per protocol.
Terbutaline to relax the uterus in tachysystole.
Ephedrine or phenylephrine, given by anesthesia, for hypotension after a block.
Therapeutic Procedures
Not in your ATI chapter — filled from StatPearls, 2024.
For a nonreassuring tracing, first reposition the mother laterally, to either side, to improve uteroplacental blood flow.
Administering supplemental oxygen to the mother is a standard intervention for a nonreassuring fetal heart rate pattern.
Discontinuing oxytocin or cervical ripening agents reduces uterine activity that may be compromising fetal oxygenation.
Amnioinfusion can relieve variable decelerations caused by cord compression during labor.
StatPearls (NCBI Bookshelf) · Fetal Heart Rate Tracing: Assessment and Clinical Interpretation · open the source →
💬 Around the patientClient Education · Interprofessional Care
Client Education
From this module — built from the notes above on this page, not a section of the ATI chapter.
Teach that accelerations are reassuring and that early decelerations are normal head compression.
Explain why she is being repositioned, rather than repositioning her silently.
Explain that the monitor tracks the baby’s response to labor, not a score of how she is doing.
Interprofessional Care
Not in your ATI chapter — filled from StatPearls, 2024.
Nurses provide continuous monitoring, early recognition of abnormal patterns, and prompt communication of concerns to the team.
Pharmacists contribute by helping optimize oxytocin adjustments and tocolytic medication use.
Neonatal specialists prepare for possible resuscitation when a concerning fetal heart rate pattern persists.
StatPearls (NCBI Bookshelf) · Fetal Heart Rate Tracing: Assessment and Clinical Interpretation · open the source →
⚠️ What goes wrongComplications
Complications
Risk of misreading FHR tracings, leading to delayed recognition of fetal compromise.
Internal monitoring carries risk of maternal or fetal infection.
Scalp electrode or IUPC placement can cause fetal trauma if inserted or migrated improperly.
Supine positioning during internal monitor placement can cause maternal hypotension.
📝 Notes & key concepts
The lines from this module that carry a number, a dose or an absolute rule — the ones that decide questions. Everything else is on the cards above.
Reassuring FHR: baseline 110–160 bpm with moderate variability of 6–25 bpm.
Late decelerations = uteroplacental insufficiency. Her bundle: left lateral → oxygen by nonrebreather ~10 L/min → STOP the Pitocin → IV fluid bolus → notify the provider. Never increase oxytocin. Documentation alone is not enough.
Epidural sequence: IV fluid bolus first to prevent hypotension → frequent maternal BP and FHR → keep her off her back → she stays in bed.
Post-epidural priority is maternal BP and fetal heart rate — maternal hypotension causes fetal bradycardia. BP 88/50 at 30 minutes = act now: reposition, IV fluids, notify. Mild itching and pelvic pressure are expected.
Tachycardia and bradycardia require 10 minutes or more at the abnormal rate — not a passing dip.
Category I needs ALL of: baseline 110–160, moderate variability, no late or variable decelerations. Category III is a sinusoidal pattern, or absent variability plus recurrent lates, recurrent variables, or bradycardia. Everything else is Category II.
Late deceleration response in order: side-lying first → stop the oxytocin → open the IV → notify → oxygen if maternal hypoxia → prepare for expedited birth.
Uterine tachysystole = more than 5 contractions in 10 min → terbutaline 0.25 mg subcut.
Internal monitoring is the only way to measure true contraction intensity — needs ruptured membranes, 2–3 cm, and a descended presenting part.
Epidural: IV fluid bolus FIRST. If hypotension develops — reposition laterally, increase fluids, oxygen, and have ephedrine ready.
Have naloxone available with systemic opioids. Butorphanol and nalbuphine cause less respiratory depression. Confirm labor is established first or you slow it.
Pudendal block goes in 10–20 min before birth for perineal anesthesia, with no systemic maternal or fetal effect.
🎯 Module quiz
Questions for this module. They also feed the Mega Quiz.
