Second Stage with a Non-Reassuring Fetal Heart Rate Pattern

This is a Category III tracing - recurrent late decelerations with minimal variability and no accelerations. Category III requires prompt evaluation and intervention.

Immediate actions, in order:

1. Call for help and notify the provider (already at bedside - confirm they agree with the plan).
2. Maternal repositioning: turn to left or right lateral, or knee-chest if needed.
3. Stop or reduce Pitocin - this is a key intervention for recurrent late decelerations with minimal variability.
4. IV fluid bolus per protocol (e.g., 500-1000 mL lactated Ringer's) to support uterine perfusion.
5. Administer oxygen if maternal hypoxia is suspected or per unit protocol; note that routine oxygen for Category II/III without maternal hypoxia is not universally recommended, so follow protocol and provider direction.
6. Vaginal exam to rule out cord prolapse and assess progress.
7. Consider tocolysis (e.g., terbutaline) if uterine tachysystole is contributing - here contractions are every 2-3 minutes, which is not clearly tachysystole, but the pattern may still be contributing.
8. Prepare for expedited delivery - vacuum or forceps if criteria are met, or cesarean if not. The provider is present; the team should be ready.

Judgment: a Category III tracing is an emergency. The nurse's role is to intervene, communicate, and prepare - not to wait for improvement before escalating.

Operative vaginal delivery requires rapid, coordinated preparation:

• Confirm criteria: full dilation, engaged head, known position, adequate pelvis, and the provider's assessment that the attempt is appropriate. The nurse assists with positioning and confirms the bladder is empty (catheterize if needed).
• Anesthesia: ensure epidural is adequate or call anesthesia for supplementation.
• Equipment: vacuum or forceps at bedside, sterile setup, and a plan for a failed attempt (cesarean).
• Neonatal team: notify nursery/NICU - operative delivery increases risk of shoulder dystocia, clavicle fracture, cephalohematoma, and subgaleal hemorrhage. Have the resuscitation team present.
• Maternal preparation: explain what is happening in plain language; the mother is tearful and frightened. Say something like: 'The baby's heart rate is showing signs of stress. We are going to help you deliver now. I will stay with you and tell you what to do.'
• Documentation: time of decision, interventions, fetal heart rate response, and personnel present.
• Post-delivery: assess for perineal trauma, hemorrhage, and retained placenta; monitor the newborn closely.

Postpartum hemorrhage risk is elevated with operative delivery and laceration:

1. Quantify blood loss (weigh sponges, use calibrated drapes) and assess uterine tone, bladder distention, and bleeding source.
2. Uterine massage and uterotonics per protocol (oxytocin infusion, then additional agents if needed).
3. IV access and fluids: ensure a large-bore IV is patent; administer fluids and blood products if indicated.
4. Vital signs: every 5-15 minutes until stable; watch for tachycardia, hypotension, and pallor.
5. Laceration repair: assist the provider; assess for extension and ensure hemostasis.
6. Newborn: confirm the neonatal team is assessing the infant; support skin-to-skin and early breastfeeding when stable, but do not delay maternal stabilization.
7. Communication: explain to the mother what is happening and why; keep her informed and involved.
8. Documentation: blood loss estimate, interventions, response, and notifications.