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NU 330 > Chapter 9 > Flashcards

Chapter 9 Flashcards

1
Q

FHR assessment can signal _____

A

fetal compromise

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2
Q

goal of EFM is to __

A

interpret and continually assess fetal oxygen to prevent significant fetal acidemia while minimizing unnecessary interventions and promote family-centered care

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3
Q

FHR =

A

fetal oxygenation

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4
Q

palpating contractions

A
  • subjective
  • can cause uterus to become tense and firm
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5
Q

nurses should palpate contractions with __

A

fingertips

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6
Q

in-between contractions, resting tone is __

A

soft

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7
Q

mild contractions

A
  • easy indented (tip of nose)
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8
Q

what do moderate contractions feel like when palpated?

A
  • slightly indented (chin)
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9
Q

strong contractions

A
  • can’t indent (forehead)
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10
Q

external electric fetal monitoring measures ____

A
  • FHR
  • contractions
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11
Q

external electric fetal monitoring: FHR

A
  • uses ultrasound transducer
  • FHR location changes as baby descends
  • lose tracing when baby moves
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12
Q

what are contractions noted/read with?

A
  • uses a toco to pick up contractions
  • toco is a strain monitor
  • doesn’t measure intensity
  • doesn’t always pick up contractions
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13
Q

internal fetal and uterine monitoring uses what?

A
  • uses fetal scalp electrode
  • membranes need to be ruptured
  • very accurate
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14
Q

internal fetal and uterine monitoring cannot be used with

A
  • herpes
  • chorioamnionitis
  • HIV
  • GBS +
  • placenta previa
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15
Q

reading FHR strips

A
  • upper graphs is FHR (bpm)
  • lower graph is contractions
  • 1 small square = 10 seconds
  • 6 small squares = 1 minute
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16
Q

FHR interpretation: areas to assess

A
  1. FH baseline
  2. periodic and episodic changes
  3. uterine activity
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17
Q

normal baseline FHR is

A

110-160 bpm
- tachycardia = >160 bpm
- bradycardia = <110 bpm

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18
Q

what is baseline variability

A
  • the small up and down bumps (roughness and smoothness) in the road
  • defined as the fluctuations in the baseline FHR that are irregular in amplitude and frequency
  • flat line 12 is never good
  • the bumps show us that the baby is neurologically doing well
  • measured in a 10-minute window, excluding decels/accels
  • more variability is seen in mature fetus’ because the parasympathetic system exerts itself more as fetus matures
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19
Q

variability is documented as

A
  • absent: undetectable range
  • minimal: < 5 bpm
  • moderate: 6-25 bpm
  • marked: > 25 bpm
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20
Q

accelerations

A

show the baby is doing well
- want to see these on strip
- an acceleration is a 15 beat rise in HR that lasts at least 15 seconds

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21
Q

VEAL CHOP MINE

A

Variable decelerations
Early decelerations
Accelerations
Late decelerations

Cord compressions
Head compressions
Oxygen good
Placental insufficiency

Maternal repositioning
Identify labor progress
No interventions
Execute interventions

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22
Q

early decelerations

A
  • OK
  • gradual decrease and return to baseline
  • gradual decrease is defined as one from the onset to the FHR nadir of 30 seconds
  • correspond to the beginning, peak and end of the contraction
  • mirror the contraction
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23
Q

cause of early decelerations

A

head compression
- which causes vaginal stimulation and slowing of the HR

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24
Q

late decelerations

A
  • BAD
  • visually apparent usually symmetrical gradual decrease and return of the FHR associated with contraction
  • gradual FHR decrease is defined as from the onset to the FHR nadir of >/= 30 seconds
  • start after the contraction starts
  • peak after the peak of the contraction
  • FHR doesn’t return to baseline until contraction is over
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25
Q

cause of late decelerations

A

placental insufficiency
- provoked by contractions
- any decrease in uterine blood flow or placental dysfunction can cause late decels

  • maternal hypotension
  • uterine hyperstimulation
  • postdate gestation
  • preeclampsia
  • chronic HTN
  • DM
  • hypovolemia
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26
Q

treatment of late decelerations

A
  • fix reason
    (if on pitocin, may d/c)
  • turn to left side
  • apply oxygen
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27
Q

variable decelerations

A
  • > /=15 beats below for >/= 15 seconds, and <2 minutes in duration
  • visually apparent abrupt decrease in FHR
  • abrupt FHR decrease is defined as from the onset of the decel to the beginning of the FHR nadir of < 30 seconds
  • decrease is calculated from the onset to the nadir of the decel
  • not consistent with contractions
  • usually in shape of V, U, or W
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28
Q

cause of variable decelerations

A

cord compression

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29
Q

NICHD category 1+

A
  • normal baseline FHR (110-160)
  • moderate variability
  • lack of concerning decelerations (no early, late or variable decels)
  • accels may be present or absent

*continue monitoring

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30
Q

NICHD category 2+

A
  • indeterminate
  • FHR patterns that are concerning enough to warrant increased frequency in monitoring, but that respond to interventions provided

*general measures
consider discontinuing oxytocin
consider potential need to expedite delivery if abnormalities persist or worsen

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31
Q

NICHD category 3+

A
  • abnormal
  • absent baseline FHR variability
  • recurrent late/variable decelerations
  • bradycardia
  • sinusoidal pattern

*general measures
discontinue oxytocin (Pitocin)
expedite delivery by operative vaginal or cesarean delivery

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32
Q

how is baseline FHR calculated?

A
  • approximating the mean FHR rounded to increments of 5 bpm during a 10-minute window, excluding accels/decels/periods of marked FHR variability (>25 bpm).
  • there has to be at least 2 minutes of identifiable baseline segments (not necessarily contiguous) in any 10-minute window, or the baseline for that period is indeterminate. (refer to previous 10-minute window if this happens)
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33
Q

how can you recognize baseline FHR?

A
  • steady, stable area where most of the FHR is plotted
  • mean FHR over 10-minute segment
  • a single value in increments of 5 bpm, not a range
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34
Q

tachycardia

A

baseline FHR is >160 bpm lasting at least 10 minutes

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35
Q

tachycardia: variability

A
  • variability may be minimal because of sympathetic dominance
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36
Q

bradycardia

A

baseline FHR is < 110 bpm lasting at least 10 minutes

  • a term or post-term fetus may have a BL FHR of 100-110 bpm because of parasympathetic maturation

*make sure the HR read is fetus’ and not mom’s

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37
Q

NICHD researchers determined that in practice, LTV and STV are visually assessed as ___

A

a single unit

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38
Q

preterm fetuses tend to have slightly ____ baselines and ___ variability

A
  • slightly higher baselines (still in normal range)
  • decreased variability
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39
Q

cycles per minute

A
  • means that horizontal dimension of variability
  • oxygenated fetuses have 2-8 cycles per minute
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40
Q

amplitude

A
  • the vertical dimension of variability
  • quantitated in bpm
  • measured from the peak to the trough of a single cycle
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41
Q

periodic patterns

A

those associated with uterine contractions

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42
Q

episodic patterns

A

those not associated with uterine contractions

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43
Q

periodic changes

A
  • accels
  • decels:
    -late
    -early
  • variable
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44
Q

episodic changes

A
  • accels
  • decels
  • variable
  • prolonged
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45
Q

a prolonged acceleration is

A

> 2 minutes but < 10 in duration

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46
Q

what makes an acceleration defined as a baseline change?

A

if the accel lasts 10 minutes

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47
Q

how are accels defined <32 weeks gestation?

A
  • peak of 10 bpm in a duration of 10 seconds
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48
Q

periodic pattern decels

A
  • early decels
  • late decels
  • variable decels
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49
Q

episodic pattern decels

A
  • prolonged decels
  • variable decels
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50
Q

acme

A

highest point of the contraction

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51
Q

nadir

A

lowest point of a decel

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52
Q

what does onset mean (context: decel)?

A

time from the start of the decel to the nadir

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53
Q

what does offset mean (context: decel)?

A

time from the nadir of the decel to the return to baseline

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54
Q

abrupt

A

less than 30 seconds

55
Q

gradual

A

at least 30 seconds

56
Q

recurrent

A

occurring with >50% of uterine contractions in any 20-minute window

57
Q

intermittent

A

occurring with <50% of uterine contractions in any 20-minute window

58
Q

what is an ominous pattern of late decels?

A

16 persistent late decels associated with decreased beat-to-beat variability

59
Q

consistent patterns of variable decels can lead to

A

acidosis and fetal distress, if not corrected

60
Q

variable decels occur most frequently in patients who have experienced ___

A
  • PROM
  • decreased amniotic fluid
61
Q

what is the most commonly encountered pattern during labor?

A

variable decels

62
Q

uterine muscles contain ___ receptors

A

adrenergic receptors

63
Q

estrogen stimulates ___ and increases ___

A
  • stimulates cervical ripening
  • increases the concentration of oxytocin receptors
64
Q

gap junctions

A
  • estrogen and progesterone form gap junctions
  • spreads nerve impulses which cause contractions
65
Q

uterine activity assessment components

A

frequency
duration
intensity

66
Q

frequency is

A

the time from the beginning of one contraction to the beginning of the next

67
Q

duration is

A

the time from the beginning to the end of a contraction

68
Q

intensity is felt by ___ as either __ __ __

A

felt by palpation
- mild, moderate, strong

69
Q

normal uterine activity is

A

</= 5 contractions in 10 minutes, averaged over a 30 minute window

70
Q

peak IUP

A

the acme of the contraction in mm HG when an IUPC is in place

71
Q

interval

A

the time from the end of one contraction to the beginning of the next
- also called the rest interval

72
Q

resting tone/baseline tone

A

the lowest intrauterine pressure found between contractions with IUPC

73
Q

tachysystole

A

more than 5 contractions in a 10 minute window averaged over a 30 minute period, regardless of FHR
- always qualified as to the presence or absence of associated FHR decels
- applied to both spontaneous or stimulated labor

74
Q

hypertonus

A

abnormally high resting tone
- above 30 mm Hg

75
Q

uterine tetany

A
  • tetanic contraction
  • a uterine contraction that is strong to palpation or > 90 mm Hg and lasts > 90 seconds
76
Q

hypertonus and uterine tetany are confirmed with ___

A

palpation

77
Q

documentation of uterine activity

A
  • method: palpation, toco, IUPC
  • frequency
  • duration (seconds)
  • intensity
  • relaxation (soft or resting tone mm Hg)
78
Q

moderate variability and/or accels exclude the presence of ___

A

metabolic acidemia

79
Q

injury requires significant ___

A

metabolic acidemia
- umbilival artery pH < 7.0 and BE </= -12

80
Q

__ __ are a protective reflex mechanism in response to transient fetal hypoxia during uterine contractions

A

late decels

81
Q

late decels are mediated by ___

A

chemo and baroreceptors

82
Q

what happens when late decels continue and are not resolved

A
  • peripheral vasoconstriction fails
  • central hypotension
  • decreased blood flow to the brain
  • hypoxic
  • ischemic injury to brain and heart
83
Q

are late decels clinically significant?

A

yes- they represent disruption in the oxygen pathway

84
Q

the intent of intrapartum FHR monitoring is

A

to assess fetal oxygenation
- but oxygenation is not the only cause of FHR changes

85
Q

fetal tachycardia: maternal factors/causes

A
  • fever
  • infection
  • dehydration
  • hyperthyroidism
  • anxiety (adrenaline)
  • medication/illicit drugs
86
Q

fetal tachycardia: fetal factors/causes

A
  • infection
  • supraventricular tachycardia or other tachycardia
  • congenital anomalies
87
Q

fetal bradycardia: maternal factors/causes

A
  • drug response
  • prolonged maternal hypoglycemia
  • connective tissue disease
88
Q

fetal bradycardia: fetal factors/causes

A
  • hypothermia
  • cardiac defect/arrhythmia
  • excessive vagal response (OP, forceps, etc.)
89
Q

absent variability: causes/factors

A
  • medications (CNS depressants)
  • severe fetal anemia
  • arrhythmias
  • congenital brain anomaly
  • cerebral ischemia
90
Q

minimal variability: causes/factors

A
  • fetus in quiescent phase
  • occurs with tachycardia (secondary to dominance of sympathetic nervous system)
  • drug effect: CNS depressants

*may be seen in very preterm fetus/baby

91
Q

marked variability: causes/factors

A
  • fetal activity
  • fetal stimulation
  • may follow epinephrine administration
  • rare in preterm fetuses; more common in post-term fetuses
  • may be seen in second stage, especially with vacuum application
92
Q

nursing actions: FHR abnormalities

A
  • develop a plan of care using terminology and interpretation
  • determine physiological goals and interventions using evidence-based guidelines
93
Q

oxygen pathway

A

environment
lungs
blood
heart
vasculature
uterus
placenta
umbilical cord
fetus

94
Q

physiological goals for abnormal FHR

A
  • maximize umbilical cord circulation
  • maximize uterine blood flow
  • maintain normal uterine activity
  • maximize oxygenation
  • reduce maternal anxiety
  • support mom, coping and comfort
95
Q

ABCDs of oxygen pathway

A

A: assess oxygen pathway
B: begin corrective measures, if indicated
C: clear obstacles to rapid delivery
D: determine decision to delivery time

96
Q

what is assessed when assessing the oxygen pathway

A
  • lungs
  • heart
  • vasculature
  • uterus
  • placenta
  • cord
  • O2 carrying capacity
  • kleihauer-betke
97
Q

oxygen pathway assessment: lungs

A

airway and breathing
supplemental oxygen
meds prn

98
Q

oxygen pathway assessment: heart

A

blood pressure and pulse
treat abnormal BP, arrhythmia

99
Q

oxygen pathway assessment: vasculature

A

blood pressure and pulse
volume status
position change
fluid bolus

100
Q

oxygen pathway assessment: uterus

A

uterine contractions and tone
exclude uterine rupture: discontinue uterine stimulants
uterine relaxants as needed

101
Q

oxygen pathway assessment: placenta

A

exclude abruption, previa, vasa previa
rapid delivery prn

102
Q

oxygen pathway assessment: cord

A

exclude cord prolapse: consider amnioinfusion
rapid delivery prn

103
Q

oxygen pathway assessment: O2 carrying capacity

A

maternal hemoglobin
MCA
peak systolic velocity

104
Q

oxygen pathway assessment: Kleihauer-Betke

A

treat maternal anemia
treat fetal anemia
rapid delivery prn

105
Q

what are the components of the classic triad of intrauterine resuscitation

A

oxygen
IV fluids
position changes

106
Q

hyperoxia can cause ____

A

free radical production and oxidative stress

107
Q

avoid supplemental oxygen if there is ___ in the tracing

A

moderate variability

108
Q

prior to using oxygen, you should discontinue what medication?

A

oxytocin

109
Q

why is a lateral maternal position better?

A

relieves pressure on the maternal inferior vena cava
improved blood return to the maternal heart
relieves cord compression by altering fetal position

110
Q

IV fluid bolus: dosage

A

500-1000 mL of an isotonic solution over 20 minutes resulted in a significant increase in SaO2

111
Q

IV fluid bolus: physiological changes

A

increases:
- intravascular volume
- cardiac output
- venous return

-preload even in maternal BP is normal

112
Q

decreased maternal BP puts the fetus at harm in what way?

A

significantly reduces perfusion of the intervillous space

113
Q

how to correct maternal BP

A
  • lateral positioning
  • ephedrine
114
Q

what does ephedrine do?

A
  • increases release of norepinephrine and stimulation of postsynaptic adrenergic receptors, which causes vasoconstriction and increased HR
115
Q

disruption in the oxygen pathway at the uterine level is most commonly caused by ___

A

excessive uterine activity

116
Q

what protocol should you use to reduce uterine activity?

A

oxytocin-induced tachysystole evidence-based protocol

117
Q

oxytocin-induced tachysystole evidence-based protocol: category 1 tracing

A
  • maternal repositioning (left or right)
  • IV fluid bolus of at least 500 mL lactated Ringer’s solution
  • if uterine activity has not returned to normal after 10-15 minutes: reduce oxytocin rate by at least half
  • if uterine activity has not returned to normal after 10-15 additional minutes: discontinue oxytocin until uterine activity is no more than 5 contractions in 10 minutes
118
Q

oxytocin-induced tachysystole evidence-based protocol: category 2/3 tracing

A
  • discontinue oxytocin
  • maternal repositioning
  • IV fluid bolus of at least 500 mL lactated Ringer’s solution
  • oxygen at 10 L/min via non-rebreather facemask (d/c as soon as possible based on fetal response)
  • give terbutaline 0.25 mg SQ if: prolonged decel, no response after 10-15 minutes
119
Q

resuming oxytocin after resolution of tachysystole

A

*If oxytocin has been discontinued for less than 30 minutes, there is a Category I tracing, and contractions are no more than five in 10 minutes
- Resume oxytocin at no more than half the rate that was being given at the time of tachysystole
- Resume titration as ordered
*If oxytocin has been discontinued for at least 30 minutes, there is a Category I tracing, and contractions are no more than five in 10 minutes:
- Resume oxytocin at initial dose ordered
- Resume titration as ordered

120
Q

open-glottis pushing technique

A
  • push fewer times with each contraction
  • push with every other or every 3rd ctx
    -push only with the urge to push have all been shown to improve FHR tracings
121
Q

amnioinfusion

A
  • replaces amniotic fluid with sterile saline
  • think oligohydramnio moms
  • relieves intermittent cord compression that may cause variable decels
  • has no effect on late decels
122
Q

nursing actions: maternal anxiety/comfort

A

include patient/family in planning care
review expectations and interventions
bedside attendance
review and determine labor coping/pain options
use technology only when needed

123
Q

determining delivery time involves ___

A
  • always involves prediction of unknown future events
  • always relies on clinical judgement
  • there will NEVER be one universal answer
124
Q

considerations to clear patient for delivery

A
  • Consider notifying: OB, Surgical Assist, Anesthesia, Neo-peds
  • Consider epidural
  • Confirm IV access, catheter
  • Labs (eg Type & Cross), blood products
  • Medications as needed
  • CHG skin prep
  • Prepare to move rapidly to OR
  • Untangle cords/tubes, clear clutter
  • Notify charge nurse
  • Confirm OR availability & readiness
  • Prepare for C/S or operative vag delivery
  • Informed Consent
125
Q

late decels: nursing actions

A
  • degree to which decel is abnormal depends on the status and response of the fetus after the decel
  • change maternal position to promote fetal oxygenation
  • d/c oxytocin (consider terbutaline) to reduce uterine activity
  • assess hydration- give IV bolus to promote fetal oxygenation
  • consider fetal scalp stimulation of VAS to assess fetal status
  • admin O2 at 10 L/min via non-rebreather mask to improve fetal oxygen status
  • consider more invasive monitoring w/ fetal scalp electrode
  • support woman and family
  • notify the provider/midwife
  • plan for delivery and care of the neonate
126
Q

intrauterine resuscitation: nursing actions

A
  • assess baseline over 10-minute period
  • promote fetal oxygenation
  • reduce uterine activity
  • alleviate umbilical cord compression
  • correct maternal hypotension
127
Q

general plan of action for decelerations

A

stop drug first
change mom’s position
add O2

128
Q

variable decels: nursing actions

A
  • decrease or d/c oxytocin
  • change maternal position to promote fetal oxygenation
  • admin O2 at 10 L/min via non-rebreather mask to improve fetal oxygenation status
  • perform a sterile vaginal exam (SVE) to evaluate cord and labor progress and perform fetal scalp stimulation
  • perform amnioinfusion if ordered to alleviate umbilical cord compression by increasing the volume of fluid in the uterus and thereby correcting umbilical cord compression
  • plan for delivery and care of neonate
  • consider the need for tocolytic to reduce contractions
  • consider more invasive monitoring with fetal scalp electrode
  • modifying pushing
  • support woman and family to decrease anxiety/pain
  • notify provider/midwife
129
Q

tetatnic contractions

A
  • type of tachysystole
  • very painful
130
Q

with recurrent decels and minimal/absent variability, _____ can evolve over approximately ___

A

fetal metabolic acidemia
60 minutes

131
Q

catastrophic uterine rupture can occur in a time frame of ____

A

17 minutes

132
Q

metabolic acidemia will occur more rapidly with what (hint: associated with FHR changes)

A
  • absent variability
  • absence of accelerations
  • worsening decelerations
133
Q

normal contraction time length:

A

2-5 minutes

NU 330 (18 decks)

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