Variable Decelerations During Second-Stage Pushing With an Epidural
A 27-year-old G1P0 at 39 weeks 4 days is fully dilated and has been pushing for 50 minutes. She has an epidural and is pushing in the semi-recumbent position. The FHR baseline is 135 bpm with moderate variability. For the last 15 minutes there have been variable decelerations to 85 to 95 bpm with a rapid drop and rapid recovery, occurring with most contractions; some last 45 seconds and some 60 seconds. Contractions are every 3 minutes lasting 60 seconds, and the IUPC shows a resting tone of 12 mm Hg. The provider is at the bedside. The patient is exhausted and asks to stop pushing. The nurse notes the decelerations began when the patient started pushing in this position.
1. Interpret the decelerations and identify the most likely mechanism and modifiable factors.
Read the worked answer
These are variable decelerations: abrupt onset, rapid descent, and rapid return, with timing that varies relative to contractions. They are recurrent (with most contractions) and some reach 60 seconds, which is prolonged enough to warrant attention even though variability remains moderate.
The most likely mechanism is umbilical cord compression, which is common in second stage as the presenting part descends and compresses the cord against the pelvis. The timing clue - onset with pushing in the semi-recumbent position - suggests that maternal position and Valsalva pushing are contributing. Pushing in a semi-recumbent position can compress the inferior vena cava and reduce venous return and uterine perfusion, and prolonged breath-holding reduces maternal oxygenation.
Modifiable factors:
- Maternal position: change to left or right lateral, hands-and-knees, or upright/kneeling to relieve cord compression and improve venous return.
- Pushing technique: shorten breath-holds and consider open-glottal or spontaneous pushing, or rest between pushes, to reduce intrathoracic pressure and improve perfusion.
- Maternal hydration and oxygenation per unit protocol.
- Reassess after each change and document response. Moderate variability is reassuring, but recurrent variables in second stage require continued vigilance and preparation for expedited delivery if the pattern worsens.
2. The patient asks to stop pushing. How do you counsel her and what is your plan for the next 15 minutes?
Read the worked answer
Counsel her that her exhaustion is understood and that resting between contractions is safe and often helpful. Explain that the decelerations are likely from cord compression and position, and that changing position and adjusting pushing may improve the baby's tracing. Be honest that if the tracing worsens, delivery may need to be expedited.
Plan for the next 15 minutes:
- Reposition to lateral or upright and reassess the tracing within a few contractions.
- Modify pushing: allow rest between contractions, avoid prolonged breath-holding, and consider spontaneous pushing. Support her with coaching and hydration.
- Continue continuous monitoring and document the pattern, position changes, and response. Notify the provider of any worsening (deeper or longer decelerations, loss of variability, rising baseline, or tachycardia).
- Prepare for possible operative vaginal delivery or cesarean if the pattern does not improve, and confirm the provider is aware and available. Keep the patient informed and involve her in decisions.
- Document the patient's request, your counseling, interventions, and the fetal response. Advocacy and shared decision-making are part of the plan, not an afterthought.