Class 5: Fetal Surveilance Flashcards
1
Q
what is the goal of intrapartum fetal surveillance (2)
A
identify potential fetal decompensation to:
- allow for timely and effective intervention
- prevent perinatal morbidity and mortality
2
Q
fetal surveilance tells us…
A
- how the fetus is adatping/coping w the stress of labor
3
Q
FHR surveillance is always assessed in conjunction with…
A
- uterine activity (contractions) in labour
4
Q
the heart rate of a healthy, well-oxygenated fetus, with a well oxygenated brain, can…
certain changes in FHR can indicate…
A
- can cope w the stress of labor
- can indicate that the fetus is experiencing hypoxia and is no longer compensating
5
Q
describe the fetal lungs role in gas exchange
A
- they do not engage in gas exchange
6
Q
how does oxygen get to the fetus?
A
- from the pregnant person
7
Q
how does CO2 get removed from the fetus?
A
- removed by pregnant person’s lungs
8
Q
what types of factors influence FHR
A
- intrinsic
- extrinsic
9
Q
what intrinsic factors impact FHR (4)
A
- medulla oblongata in the brainstem (CNS)
- autonomic nervous system
- baroreceptors
- chemoreceptors
10
Q
baroreceptors respond to? what can cause increased/decreased FHR?
A
- respond to changes in BP
- high BP = decreased FHR
- low BP = increased FHR
11
Q
what do chemoreceptors respond to?
A
- respend to changes in O2 and CO2 in blood
ex. hypoxia, acidosis
12
Q
what impact does the SNS have on the fetal CVS (2)
A
stimulation produces:
- increase in strength of cardiac contraction
- increase in FHR
13
Q
what impact does the PSNS have on the fetal CVS? (2)
A
stimulation of the vagus nerve:
- slows the SA node rate of firing thus producing a decrease in FHR
- vagal tone increases as gestational age increases and produces a downward effect on the baseline FHR
14
Q
the “slow down” responses of the PSNS and “speed up” influence of the SNS create a relationship with…
A
- relationship w baseline variability
15
Q
what are extrinsic factors
A
- factors in the fetal enviro that affect the availability of oxygen and the ability to transport oxygen to the fetus = impacting FHR
16
Q
what are 3 extrinsic factors that influence FHR
A
- maternal factors
- uteroplacental factors
- fetal factors
17
Q
what maternal factors influence FHR (4)
A
- decreased maternal arterial oxygen tension
- decreased maternal oxygen carrying capability
- decreased uterine blood flow
- chronic maternal conditions
18
Q
what can cause decreased maternal arterial O2 tension (6)
A
- resp disease
- hypoventilation ** (ex. Mg sulphate, morphine & fentanyl)
- seizure ** (ex. eclampsia)
- trauma
- smoking
- obesity
19
Q
what can cause decreased O2 carrying capability (2)
A
- signif anemia **
- carboxyhemoglobin
20
Q
what can cause decreased uterine blood flow (4)
A
- hypotension
- regional anaesthesia –> hypotension r/t epidural
- maternal positioning –> supine hypotension
- HTN disorders of pregnancy
21
Q
what type of chronic maternal conditions can impact FHR? what are 3 examples?
A
vasculopathies:
- systemic lupus erythematosus
- DM1
- chronic HTN
22
Q
what uteroplacental factors influence FHR (2)
A
- excessive uterine activity
- uteroplacental dysfunction
23
Q
what are examples of excessive uterine activity (2)
A
- tachysystole secondary to oxytocin, prostaglandins, or spontaneous labor
- placental abruption
24
Q
what can cause uteroplacental dysfunction (4)
A
- placental abruption
- placental infarction
- chorioamnionitis
- uterine rupture
25
placental infarction is dysfunction marked by... (4)
- IUGR
- oligohydramnios
- abnormal doppler studies
- lesions on placenta
26
what impact do uterine contractions have on FHR?
- uterine arteries and veins pass thru the myometrium
- contractions = increased pressure in myometrium = compression of blood vessels = blood flow impeded to fetus due to compression of the blood vessels
27
during labor, O2/CO2 exchange occurs primarily when?
- between uterine contractions when the blood flow is unimpeded
28
what impact does tachysystole (excessive uterine contractions) have on the resting period between contractions
- decreases the resting period between
29
what fetal factors influence FHR (2)
- cord compression
- decreased fetal O2 carrying capacity
30
what can cause cord compression (2)
- oligohydramnios
- cord prolapse or entanglement = polyhydramnios
31
what can cause decreased fetal O2 carrying capacity (2)
- signif anemia
- carboxyhemoglobin
32
what can cause signif anemia in the fetus (3)
- isoimmunization
- maternal-fetal blled
- ruptured vasa previa
33
what can create carboxyhemoglobin
- if birther is a smoker
34
what are methods of fetal surveillance in labor (2)
- intermittent auscultation (IA)
- continuous electronic fetal monitoring (EFM)
35
IA includes... (2)
- monitoring of uterine contractions
- IA of FHR
36
EFM includes.. (2)
- electronic monitoring of uterine contractions (internal & external)
- electronic monitoring of FHR (internal & external)
37
is external or internal monitoring w EFM the standard?
- external = standard
- internal = bigger risk of infection
38
how many fetuses can EFM monitor
- two
39
what FHR assessments are done w IA? (3)
- baseline
- rhythmn (IA only)
- changes in FHR
40
what is assessed r/t rhythm w IA (2)
- regular
- irregular
41
what is assessed r/t changes in FHR with IA (2)
- accelerations
- decelerations (relationships to contractions)
42
what is assessed r/t uterine contractions when performing IA (4)
- frequency
- duration
- intensity
- resting tone
43
what FHR assessments are done w continuous EFM (3)
- baseline --> rate
- variability
- changes in FHR
44
what is assessed r/t changes in FHR w EFM (2)
- accelerations
- decelerations (relationship to contractions)
45
what is the recommended method of monitoring fetal surveillance for healthy term pregnant persons in spontaneous labor?
- intermittent auscultation
46
increased use of EFM is linked to?
- rising c-section birth rates
47
what types of conditions exist that increase the risk of adverse fetal outcomes ? therefore, what type of monitoring is usually recommended in these situation?
- both antepartum (maternal and fetal) and intrapartum (maternal and fetal)
- continuous EFM
48
what maternal antepartum conditions are associated w increased risk of adverse fetal outcomes (6)
- HTN disorders of pregnancy
- DM
- antepartum hemorrhage
- maternal medical conditions
- maternal MVA/trauma
- birth perception of decreased fetal mvmt
49
what fetal antepartum conditions are associated w increased risk of adverse fetal outcomes (7)
- IUGR
- prematurity
- oligohyramnios
- abnormal umbilical artery doppler
- isoimmunication
- multiple pregnancy
- breech presentation
50
what maternal intrapartum conditions are associated w increased risk of adverse fetal outcomes (9)
- vaginal bleeding in labor
- intrauterine infection/chorioamnionitis
- previous c-section
- prolonged membrane rupture (>24 hrs at term)
- induced labor
- augmented labor
- hypertonic uterus
- preterm labour
- postterm labor (>42 weeks)
51
what fetal intrapartum conditions are associated w increased risk of adverse fetal outcomes (2)
- meconium-stained amniotic fluid
- abnormal FHR on intermittent auscultation
52
what is included in nursing care with both IA and EFM (6)
- leopold's maneuver
- assess uterine activity and FHR characteristics
- interpretation/classification of FHR pattern
- interventions as needed
- communication & documentation
- continued supportive care in labour
53
what is the freq of assessment of FHR and uterine activity in 1st stage of labour; latent vs active
- latent phase: hourly of w signif change
- active labour: q15-30 min
54
what is the freq of assessment of FHR and uterine activity in 2nd stage of labour; latent vs active
- latent: q15-30 min
- active: q5 min
55
what might change the freq of assessment of FHR and uterine activity during the 1st and 2nd stage of labour (3)
- rupture of membranes
- admin of meds and anaesthesia
- changes in clinical picture/complications or changes of FHR pattern
56
we should always assess FHR after... why?
- ROM
- d/t concern of cord compression/prolapse
57
describe the procedure for leopold's maneuver (5)
- wash hands
- empty bladder
- supine position, knees slightly flexed (slight R or L tilt)
- 4 maneuvers
- document (based on facility protocol/guideline)
58
what is intermittent auscultation? what kind of assessment?
- assessing fetal heart sounds at periodic intervals
- auditory only, not visual
59
what are the 7 steps of intermittent auscultation
1. explain
2. leopold's maneuver
3. palpate contractions at fundus
4. place IA US fetoscope device over area of maximal intensity
5. compare to maternal radial pulse
6. listen for 60 seconds immediately after uterine contraction
7. interpert findings and document
60
what is include in the palpate step of IA (2)
- uterine activity
- note freq and duration of contractions and palpate resting tone
61
when should you listen for 60 seconds during IA
- immediately after uterine contractions
62
what is included in the listening step of IA (3)
- record FHR baseline
- note rhythm of FHR (regular? irregular? must do for 60 sec)
- identify presence of acceleration or decelerations --> relationship to contractions?
63
what is included in the interpret & document step of IA (4)
- is FHR normal or abnormal?
- communicate
- interventions
- decision making
64
what are the steps for EFM? (9)
- leopold's maneuver
- seperate transducers for assessment of FHR & uterine contractions
- cotinuous strip of fetal monitor paper
- record FHR baseline
- note FHR variability
- identify presence of accelerations & decelerations --> relationship to contractions
- interpret findings and document
- is the FHR tracing/pattern normal, atypical, or abnormal?
- communicate, interventions, decision making
65
for uterine contractions, where is the tocotransducer placed with EFM? what does this monitor?
- on the fundus above the umbilicus
- monitors freq and duration
66
how is the intensity and resting tone of uterine contractions assedssed w FHR?
- by palpation
67
what is the FHR transducer placed with EFM? what does it do?
- placed over area of maximal intensity (external)
- continuous printout of fetal heart rate
68
what does the continuous fetal monitor paper printed from EFM record? this is sometimes called?
- records both FHR and uterine activity (contractions)
- sometimes called FHR tracing
69
how is uterine activity/contraction freq and duration assessed w IA? EFM?
how is intensity and resting tone of contractions done in both methods?
- manual counting of freq and duration --> IA
- monitor EFM --> freq and duration
- intensity and resting tone --> palpations --> both EFM and IA
70
what is the freq of normal uterine activity (2)
- contractions not more than q2min
- max of 5 contractions in a 10 min period, averaged over 30-min time period
71
frequency of uterine contractions is measured in minute from ____ to ____
- from start of 1 contraction to start of another
72
what is the duration of normal uterine activity? duration is in seconds from __ to ___
- lasting less than 90 sec
- start of 1 contraction to end of same contraction
73
what is the resting tone of normal uterine activity
- min 30 sec of rest in between
74
what is the intensity of normal uterine activity (2)
- mod to strong
- allow for uterine relaxation
75
what is considered tachysystole
>5 contractions in 10 min, averaged over 30 min time period
76
what is needed to determine baseline FHR with EFM
- need 10 min of FHr tracting
77
baseline FHR excludes...
- accelerations
- decelerations
78
what is normal baseline FHR at term
110-160
79
what is considered fetal tachycardia
>160 bpm for >10 min
80
what can cause fetal tachy
- maternal fever
- maternal infection
81
what is considered fetal bradycardia
<110 bpm for >10 min
82
what can cause fetal bradycardia
- late/post term
83
baseline FHR should be present for..
- at least 2 min in any 10-min segment to be determined
84
rhythm of FHR can only be assessed with?
- IA
85
variability of FHR can only be assessed with?
- EFM
86
define: variability
- fluctuation or range in the baseline FHR
87
what are 4 categories of variability
- absent
- minimal or decreased
- mod or average, normal
- marked or increased
88
what range is considered absent variability
0-2 bpm
89
what range is considered minimal or decreased variability
- < or equal to 5bpm
90
what range is considered moderate or average/normal variability
- 6-25 bpm
91
what range is considered marked or increased variability
> 25 bpm
92
periodic changes in FHR occur with?
- occur w uterie contractions
93
what are episodic (or non-periodic) changes in FHR
- not associated w uterine contractions
94
what is an acceleration of FHR
- abrupt increase in FHR above baseline
95
how many bpm is considered an acceleration? min time? max time?
- at least 15 bpm above baseline
- lasts 15 sec or longer
- less than 2 min
96
FHR accelerations are an indiciation of ?
- fetal well being
- classified as normal
97
FHR accelerations are documented as? (2)
- present
- absent
98
decelerations are described by their relationship with...
- contractions and shape
99
what are early decelerations?
- gradual decrease and return to baseline of the FHr during a contraction
100
with early decelerations the lowest point of the deceleration occurs?
- at the same time as the peak of the contraction
101
describe the relationship between the deceleration and contraction with early decelerations
- mirror each other
102
early decelerations are associated w?
- head compression
103
how can head compression cause decreased HFR
- puts pressure on vagus nerve = decreased FHR
104
early decelerations are generally...
- normal and benign
105
describe the appearance of late decelerations (3)
- uniform
- repetitive
- shallow
106
what are the onset of late decelerations
- occur after beginning of the contraction
107
when does the lowest point of late decelerations occur?
- after peak of contraction
108
what do late decelerations return to baseline?
- after the contraction ends
109
what do late decelerations mean?
- ominous sign
110
late decelerations are classified as...
- atypical or abnormal
111
late decelerations indicate
- uteroplacental insufficiency
112
what is a variable deceleration
- abrupt decrease in FHR
113
what is classified as a variable deceleration
- decrease in FHR > or equal to 15 bpm
- lasting for > or equal to 15 secs
- and < 2 min in duration
114
how do variable decelerations appear?
- dramatic, rapid response
- appearance of an icicle
- U, V, or W shaped
115
what do variable decelerations occur
- during or between contractions
116
variable decelerations often occur with?
- cord compression --> not always dangerous compression (could just be a position change)
117
how does cord compression cause decreased FHR
= activates SNS = increased HR = HTN = decreased FHR
118
variable decelerations are either...
- complicated
- uncomplicated
119
variable decelerations are classified as.. (3)
- normal
- atypical
- abnormal
120
what makes a variable deceleration considered normal
- if 1 time occurrence
121
if variable decelerations have a relationship w contractions, what is the concern?
- concern of prolapse
122
what does it mean if variable decelerations are reoccurring?
- atypical/abnormal, of concern
123
what are prolonged decelerations
- visually apparent decrease (either gradual or abrupt) of at least 15 bpm below the baseline and lasting more than 2 min but less than 10 min
124
what is included in normal classification of FHR with IA r/t baseline, rhythm, decelerations, accelerations
- baseline 110-160
- rhythm = regular (no skipped beats)
- no decelerations
- accelerations may be present
125
what is included in normal classifications of FHR with EFM r/t baseline, variability, decelerations, accelerations
- baseline 110-160
- variability 6-25 bpm or <5 bpm for <40 min
- decelerations = none present OR occasional uncomplicated variables or early decelerations
- accelerations = spontaneous accelerations present OR accelerations present w fetal scapl stimulation
126
what is intrauterine resuscitation
- is sometimes used to refer to specific interventions initiated when an atypical or abnormal FHR patter is noted
- mngmt of atypical and abnormal FHR with corrective measures
127
what are the goals of intrauterine resus (4)
- improve umbilical blood flow
- improve umbilical circulation
- improve O2 sat
- reduce uterine activity
128
what can improve uterine blood flow & decompress umbilical cord
- moving mother side to side
- position changes
129
what are examples of intrauterine resus interventions (8)
- stop or decrease oxytocin
- change maternal position
- IV fluid bolus
- perform vaginal exam
- consider amniofusion
- reduce maternal anxiety
- coach birther to modify breathing or pushing techniques
- assist physician w fetal scalp sampling
130
what is amniofusion
- injection of fluid into membranes
131
fetal scalp sampling is used to?
- guide decision making concerning fetal status
132
what is collected from a fetal scalp sample?
- collect a capillary fetal blood sample
133
what is the min gestational age for fetal scalp sampling
- must be >34 weeks gestations
134
how dilated does the cervix need to be to collect a fetal scalp sample
- 4-5 cm
135
how is a fetal scalp sampling sample collected? what must have happened for this?
- thru the dilated cervic with small incision to fetal scape
- membranes must be ruptured
136
when is fetal scalp sampling done?
- when FHR tracing is atypical or abnormal
- AND birth is not imminent
137
what is assessed w fetal scalp sampling
- pH
138
what does a pH of <7.20 mean? what is indicated?
- risk of fetal acidemia
- delivery is indicated
139
what does a pH of >7.20 mean?
- may continue and reassess within 30 min
