Class 4 - fetal health and surveillance Flashcards
What is important factor in fetal well being and why?
Utero-placental function
because of GAS EXCHANGE
blood flow/nutrients
What are the 3 important shunts in the fetal heart?
- ductus venosus - shunts to inferior vena cava
- Foramen Ovale - shunts to vital organs from placenta
- Ductus Arteriosus - takes blood away from the heart
What transports O2 TO Fetus, arteries or veins?
Veins (oxygenated blood)
What transports Co2 AWAY from the fetus, arteries or veins?
arteries (deoxygenated blood)
What substitutes the lungs in the fetus for gas exchange?
the placenta
What is placental function dependent on?
Maternal blood pressure supplying circulation
What two things can decreased circulation to the placenta lead to for the fetus and neonate?
- negative fetal outcomes:
-IUGR
- fetal hypoxia
- metabolic acidosis (too much H)
- still born (fetal death) - Neonatal outcomes
- small for gestational age
- low birth weight
- metabolic acidosis
- seizures
- cerebral palsy
- neonate death
What is a common disorder in neonates when placenta is not effectively perfused?
Cerebral palsy
Why are we worried about someone going too far over 40 weeks?
the placenta starts to calcify
decrease gas exchange
What maternal factors can lead to issues with placenta gas exchange?
-contractions (yes big stressor) – try to space them out, give them a break between contractions
-hypotension
-hypertention
-seizures
-meds /pain meds (opiods - depress resps
- smoking
What are three factors that can affect a placenta from good gas exchange?
- infection
- placental abruption
- placenta previa
What can the fetus do by accident that restricts gas exchange for the placenta?
cord compression
What can affect oxgyenation in labour?
contractions
it’s like baby has to hold their breath until the contraction is over.
- too many
- too long can be a problem
When do we do FHS with FHR monitoring?
- Third trimester
- labour and birth
What are the 3 goals of the FHS (fetal health surveillance) ?
- detect - potential decompensation
- Intervene - early enough
- prevent perinatal/neonatal morbidity and mortality
Since we can’t measure the fetus brain, what test do we do to help us identify patterns of concern?
FHS (fetal health survellance)
- NST
- BPP
-sometimes a contraction test (rare)
When someone has contractions, is FHR necessary?
YES! FHR is ALWAYS assessed with uterine activity (contractions)
what is resting tone?
the rest period for the fetus between contractions
how do contractions affect the placenta/gas exchange on a physiological level?
contractions increase pressure in the blood vessels.
vessels begin to collapse and restrict blood flow to placenta
What is Tachysystole?
too many contractions
> /= 6
or last over 90 sec
in 10 min
What interventions can we do for tachysystole?
- slow down contractions:
1. reduce augmentation or stop induction
2. fluids
3. monitor to see fetal response.
What is the correct amount of time to allow fetus to correct itself after contraction intervention?
30 min
What is normal contraction frequency?
</= 5 in 10 min
What three purposes do contractions serve for labour?
- cervix to thin & dilate
- fetus decend further into birth canal
- birth placenta and membranes
What are the 4 things we monitor during contractions?
1.Frequency – how often – from the beginning to the end of 1
2.Duration- how long
3. Intensity – palpate uterus
4. Resting Tone – time in between
How do we measure contraction intensity?
Manual!
1. weak - feels like my nose
2. moderate/mild- feels like my chin
3. severe/intense - feels like my forehead
How long do contractions normally last?
45-80 seconds
max 90 sec
Aside from contraction frequency >5 / 10 min averaged over 30 min, what are the 3 other factors that can be considered tachysystole?
- contraction >90 sec
- resting tone is <30 sec
- uterus remains firm (>25mm Hg via internal monitor)
What is IA?
Intermittent auscultation
(the doppler)
What is Electronic fetal monitoring (EFM)?
continuous
monitors
1. contractions
2. FHR
What do the top and bottom sensor monitor with EFM?
top- contractions - toco
bottom- FHR - ultrasound
What are the 3 things we want to check with intermittment auscultation?
- baseline of fetus (FHR)
- Rhythm of FHR
- accelerations /decelerations
What do we do if we hear decelerations with the IA?
put them on EFM (the monitor)
What is a normal fetal HR?
110-160 bpm
What 5 things do we look for in electronic fetal monitoring (EFM)?
- FHR baseline
- FHR variability
- Presence of accelerations or decelerations
- contractions
- FHR pattern
What 4 things do we monitor with contractions?
- frequency
- duration
- intensity
- resting tone
How many min of FHR tracing do we need to determine baseline?
10 min of segment
(at least 2 min in a 10 min segment)
What do we not include when looking at baseline?
accelerations
decelerations
marked variability
What is fetal tachycardia?
> 160 bpm for >10 min
What is tachycardia classified as?
atypical
abnormal
What is fetal bradycardia classified as?
<110 bpm for >10 mi
What can umblilcal cord compression be caused by?
- Oligohydramnios
- cord is between baby and mom pelvis
- Cord around fetal neck (nuchal cord), arm, leg, or other body part
- Short cord
- Knot in cord
- Prolapsed umbilical cord
What do we want to see with FHR and why?
variability
autonomic nervous system is working
-sympathetic -speed up & parasympathetic- slow down
What is more important than random decelerations and why?
variability
because it shows that baby can cope with changes in pressure
What is absent range measurement for variability?
0-2 bpm
What is minimal or decreased range measurment of variabiilty?
</= 5 bpm
What is moderate or average -normal range of measurement of variability?
6-25 bpm
What is marked or increased measurement of variability?
> 25 bpm
What can the fetus be experiencing if we see minimal or absent variability?
Hypoxemia
metabolic acidemia
What are some reasons for absent or minimal variability?
sleep cycle
fetal tachycardia
meds
prematurity
congenital abnormalities
fetal anemia
infection
other fetal conditions
What rhythm do we see if the HR is sinusodial pattern?
Severe fetal anemia
What is the definition of an acceleration?
abrupt increase in FHR above baseline (onset to peak is <30 sec)
15 bpm above baseline (min)
lasts 15 sec or longer bu less than 2 min
What do accelerations represent?
fetal alertness or arousal states
How do we document accelerations?
present
absent
What are the 4 types of decelerations?
- early decelerations
- late decelerations
- variable decelerations (not variability)
- prolonged decelerations
What defines the type of deceleration?
it’s relationship to the contraction
their shape
What are repetitive decelerations?
> /= 3 in a rowW
what are recurrent decelerations?
occur with >/= 50% of uterine contractions
must be in 20 min window
What are intermittent decelerations?
occur with <50% of uterine contractions
must be in 20 min window
What are early decelerations?
Lowest point of deceleration happens at same time as peak of contractions.
Mirrored U shapes
What are early decelerations associated with?
transient fetal head compression (vaginal reflex)
What are late decelerations?
Uniform
repetitive
shallow
onset occurs AFTER the start of the contraction
Lowest point occurs AFTER the peak of contraction
Returns to baseline AFTER the contraction ends
Which is the worst type of deceleration?
Late deceleration
ominous sign
What is late decelerations associated with?
fetal hypoxemia
acidemia
low Apgar scores
What are late deceleration classified as?
atypical
abnormal
What do we see uteroplacental insufficiency?
late decelerations
Why does baby’s HR decrease during contraction?
Vagus nerve gets stimulated
d/t
1. low O2 levels in fetus
2. fetal hypertension
If there are late decels in over 50% of the contractions do we classify it as abnormal or atypical?
abnormal
If late decels happen occasionally what do we classify it as, abnormal or atypical?
atypical
How are variable decelerations defined?
- ABRUPT decrease in FHR
- decrease in FHR >/= 15 bpm - for >/= 15 sec. and <2 min duration
- looks like an icicle , U,V,W shape- sudden drop, quick return
- DURING or BETWEEN contractions
- repetitive
- complicated/uncomplicated
What do variable decelerations often indicate?
cord compression
How do we classify variable decelerations?
normal
atypical
abnormal
What do we do if we see variable decelerations?
- interuterine recussitation
- confirm fetal well being
What are nursing interventions for someone with variable decelerations?
- Change patient position (side to side, knee chest).
- Consider need for intrauterine resuscitation
- Notify primary care provider.
- Assess for possible cord prolapse.
- Assist with scalp stimulation, scalp pH or lactate, or amnioinfusion
- Alter pushing technique (e.g., open glottis, shorter pushes).
- Assist with birth (vaginal assisted or Caesarean) if pattern cannot be
corrected.
what causes uncomplicated variable decelerations?
when the veins and arteries get squished during a contraction, signals are sent to the brain to activate the vagus nerve and
the sympathetic system slows the heart (deceleration)
What 3 questions do we ask ourselves about variable decelerations?
- how quickly did it drop?
- are there shoulders?
- how long does it take to go back to baseline?
What is a complicated variable deceleration?
doesn’t go back to baseline by the end of contraction
> /= 60 seconds long
AND
down to </= 60 bpm
OR
decrease by >/= 60 bpm below baseline
What are complicated variables associated with?
baseline abnormality:
1. absent/minimal variablitiy (not variables- diff word)
2. tachycardia/bradycardia
What are prolonged decelerations?
visually apparent
15bpm below baesline and more than 2 min
less than 10 min
What are we worried about with prolonged decelerations?
bradycardia
hypoxia
How do we tell the diff between variablity and variable deceleration?
variablity = <15 bpm or <15 sec decel.
variable decel = >15 sec bpm or >15 sec
What type of decels are we ok with during FHR with EFM?
-no decels
-occasional uncomplicated variables
- early decels
If someone is >/=37 weeks how do we like to montior them?
IA
How often do we monitor FHR with IA in the first stage (latent phase)?
Q 1 hr
How often do we monitor FHR with IA in the FIRST stage/second stage (passive phase)
Q15-30 min
How often do we monitor FHR with IA in second stage (active phase?)
q 5 min
What is unique to IA that we don’t assess with EFM?
Rhythm
-reg/irreg.
What is unique to EFM that we don’t do with IA?
variability
What indicates the need for intrauterine resuscitation?
an ATYPICAL or ABNOMAL FHR pattern is noted
What are the 4 goals or intrauterine resuscitation?
- *Improve uterine blood flow
- Improve umbilical circulation
- Improve oxygen saturation
- Reduce uterine activity (slow contractions)
What are 3 priorities in intrauterine rescusitation?
1.Stop or decrease Oxytocin (in induction/augmentation of labour)
2. Change maternal position (to left or right lateral…)
3. Check birther’s vital signs, including differentiation of the pulse from FHR (maternal sat. monitor – EFM strip)
What are some other interventions that could be indicated if there’s an aypical or abnormal FHR tracing?
- IV fluid bolus (birther hypovolemia and/or hypoxia) - if indicated.
- Perform vaginal examination (rule out cord prolapse, scalp stimulation)
- Assist with IV tocolysis as ordered (i.e. tachysystole)
Assist with amnioinfusion as ordered (if amniotic fluid thought to be low) - (rare) Consider administration of oxygen (8 – 10 L/min) by mask – ONLY when maternal hypoxia and or hypovolemia is suspected/confirmed = for maternal resuscitation, not fetal resuscitation
What is the purpose of fetal scalp samping?
- blood sample for pH
- see how much time we have
- if the baby can handle it
How do we classify IA?
normal
abnormalH
How do we classify EFM pattern?
Normal
Atypical
Abnormal
When are we worried about fetal tachycardia?
- When there are decels (variable or late
and or
- absent variability
What do we document for FHR?
- baseline rate
- variability (must be <15 sec) present/absent
- accelerations
- Decelerations (must be >15 sec)
- changes in trends/patterns
- uterine contraction pattern
- classification of uterine pattern (duration, frequency)
