Electronic Fetal Monitoring & Fetal Adaptation to Labor (exam 2) Flashcards
1
Q
fetal monitoring allows for
A
ongoing assessment of fetal oxygenation
2
Q
the fetal heart circulates _______ from the placenta throughout the body and returns _________ to the placenta
A
oxygenated blood
deoxygenated blood
(opposite from adult - switches when born)
3
Q
carries deoxygenated blood from the fetus to the placenta
A
2 arteries
4
Q
carries oxygenated blood to the fetus
A
1 vein
5
Q
adequate oxygenation promotes
A
normal function of the autonomic nervous system, enabling the fetus to adapt to the stress of labor
6
Q
types of monitoring
A
- auscultation/intermittent auscultation
- external fetal monitoring
- internal fetal monitoring
7
Q
advantages of auscultation
A
- non-invasive
- fetoscope detects actual fetal heart sounds, therefore you can hear dysrhythmias (rarely used anymore)
- no straps to hold mother down
- no “machine error”
8
Q
disadvantages of auscultation
A
- requires skill and practice
- can be disrupted by contractions
- unable to review or archive the information
9
Q
FHR is obtained by
A
- doppler
- fetoscope (rarely used)
10
Q
external monitoring of FHR
A
- tocotransducer (maternal monitoring)
- ultrasound (fetal monitoring)
11
Q
uterine activity is measured in
A
mmHg
12
Q
internal monitoring
A
- internal scalp electrode (ISE) for fetal
- intrauterine pressure catheter (IUPC) for maternal
13
Q
internal EFM advantages
A
- true reading of FHR
- can detect arrhythmias
- helpful with obese patients
14
Q
internal EFM disadvantages
A
- BOW must be ruptured
- cervix must be dilated
- invasive - can lead to infection
15
Q
external EFM advantages
A
- continuous
- captures/archives data that can be retrieved later if necessary
- becomes a permanent part of the patient’s chart
- able to visualize fetal responses before, during, and after a contraction
- allows staff to watch more than 1 mother at a time
- can be used whether or not water is ruptured
16
Q
external EFM disadvantages
A
- restricts movement
- can lose contact with maternal or fetal movement
- can half or double the rate?
- difficulty with obese pts
- contractions must be palpated
17
Q
monitoring strip top = bottom = each vertical dark read line = each small square = 6 columns of squares =
A
top = FHR bottom = uterine activity each vertical dark read line = 1 minute each small square = 10 sec 6 columns of 10 sec squares = 1 min
18
Q
top of the contraction
A
acme or peak
19
Q
baseline FHR
A
110-160 bpm
20
Q
average HR measured on EFM strip
A
measured for 2 “clear” minutes and rounded to 5 bpm
- uterus must be at rest
21
Q
FHR >160 lasting more than 10 min
A
tachycardia
22
Q
FHR <110 lasting more than 10 min
A
bradycardia
must watch closely to differentiate between bradycardia and prolonged decelerations
23
Q
fetal tachycardia causes
A
- early fetal hypoxemia
- maternal fever
- maternal dehydration
- drug induced
- intraamniotic infection
- maternal hyperthyroidism
- fetal anemia
- fetal HF
- fetal cardiac dysrhythmias
24
Q
drugs that can cause fetal tachycardia
A
- atropine
- hydroxyzine (Vistaril)
- terbutaline (brethine)
- ritodrine
- cocaine
- methamphetamines
25
fetal bradycardia causes
- late fetal hypoxemia/hypoxia
- drug induced
- prolonged umbilical cord compression
- fetal congenital heart block
- maternal hypothermia
- prolonged maternal hypoglycemia
- last sign of hypoxia
26
drugs that can cause fetal bradycardia
- MgSO4
- propranolol
- anesthetics
- epidural
- stall
27
most reliable indicator of fetal well-being
variability
28
fluctuation in the baseline FHR
variability
- the normal irregularity of cardiac rhythm resulting from continuous balancing interaction of the sympathetic (cardioacceleration) and parasympathetic (cardiodeceleration) branches of the ANS
29
things that can affect variability
- fetal movement
- fetal breathing (moderate)
- fetal sleep (minimal)
- narcotics or sedatives (minimal)
- alcohol or illicit drugs (marked or absent)
- fetal sepsis
- fetal tachycardia
- gestation <28weeks
- hypoxia
- fetal anomalies
30
absent variability
undetectable
31
minimal variability
< 5bpm
can occur with tachycardia, extreme prematurity, or when fetus is temporarily in a sleep state (does not usually last longer than 30min)
32
moderate variability
6-25 bpm
considered normal - its presence is highly predictive of a normal fetal base balance
33
marked variability
> 25 bpm
34
variability indicates
ability of fetus to neurologically modulate FHR in response to oxygen needs
35
non-reassuring variability
absence
36
factors that decrease variability
Drugs
- narcotics, tranquilizers, barbiturates, and anesthetics depress CNS mechanisms for cardiac control (stadol, magnesium sulfate)
- variability returns as drug is excreted
Fetal Heart Problems
- anomalies or arrhythmias (nothing reverses)
Fetal Sleep State
- decreases variability (usually returns in 20-30 min)
Hypoxia/Acidosis
- uteroplacental insufficiency
- absence of variability associated with late decelerations of any magnitude is a sign of advanced hypoxia and acidosis that is related to CNS depression
37
factors that increase variability
Mild Hypoxia
- early compensatory mechanism produces an increase in variability
Fetal Stimulation
- external uterine palpation, uterine contractions, fetal activity, application of ISE, SVE, acoustic stimulation, maternal activity -- will stimulate fetal autonomic nervous system resulting in increase in variability
Street Drugs
- variability reflects CNS excitability in response to cocaine and other street drugs
38
changes in FHR that are transient changes (accels or decels) from baseline occurring in response to uterine contractions
periodic changes
late and early decels are always periodic
39
accels or decels that occur without any specific relationship to uterine activity
```
episodic changes
(aka non-periodic)
```
- not associated with contractions
40
an abrupt, temporary increase in the FHR that peaks at least 15bpm above the baseline and lasts at least 15 seconds
(for fetus at least 33 weeks)
accelerations
can be periodic or episodic
if the fetus is <33 weeks, 10bpm above baseline and lasting 10 sec is acceptable
41
acceleration that lasts longer than 2 minutes but less than 10 minutes
prolonged acceleration
42
acceleration that lasts more than 10 minutes
new baseline
43
accelerations are a sign of
a well oxygenated fetus and/or fetal movement, fetal well-being, and is reassuring
44
help in defining reassuring and non-reassuring
accelerations
45
etiology of accelerations
- fetal movement
- vaginal exam
- internal scalp electrode application
- fetal scalp stimulation
- fetal reaction to external sounds or stimulations
- breech presentation
- uterine contractions
- partial cord compression of the umbilical vein resulting in decreased fetal venous return
ALWAYS REASSURING
- normal pattern indicated fetal acid-base balance
- no nursing intervention required
46
types of decelerations
1. early (ear - head compression)
2. variable (vise - compresses cord)
3. late (uteropLAcental insufficiency - tired uterus/placenta)
47
looks like a mirror image of a contraction - gradual descent from baseline, and returns to baseline by the end of the contraction
MUST be periodic
early decelerations
48
cause of early decelerations
head compression -> reflex vagal response with resultant slowing of FHR during UC
(NOT associated with fetal compromise and require NO intervention)
49
abrupt rise and fall from baseline (looks like a "V" or "W")
| - the decrease in HR is at least 15bpm and lasts at least 15sec but less than 2 min
variable deceleration
- repetitive variables can indicate a recurrent disruption of fetal oxygen supply
- usually found in transition phase when cord is being stretched or compressed during fetal descent
50
causes of variable decelerations
Cord Compression
| - can be caused by cord trapped between structures, wrapped around neck, leg, abd, etc., and become compressed with UC
51
FHR decreases often at the peak of the contraction and returns to baseline after the contraction has already ended
- MUST be periodic
- impairment of placental/oxygen exchange
late decelerations
52
causes of late deceleration
```
Uteroplacental insufficiency
(placental/oxygen exchange impaired)
```
- maternal hypotension/hypertension
- diabetes
- decrease in fetal oxygen reserves
- maternal supine position
- epidural anesthesia
- placenta previa/abruption
- post maturity
- IUGR
53
Big 5 Interventions of late decelerations
1. REMOVE -> stop the oxytocin/pitocin
2. REPOSITION -> turn the patient or reposition the patient
3. REOXYGENATE -> O2/facemask - 8-10L
4. REHYDRATE -> IV fluids or fluid bolus
5. REPORT -> call HCP
```
other interventions:
- evaluate the pattern
- identify the cause
Consider:
- elevating legs if hypotensive
- palpating uterus if tachysystole (ctx closer than 2min apart) is suspected
- internal monitoring
- assisting with birth if not corrected
```
54
EFM used to see how the fetus responds to contractions
contraction stress test (oxytocin challenge test)
- contractions decrease uterine blood flow and placental perfusion -> if the decrease produces hypoxia in the fetus, FHR decelerations occur
- 10-20min baseline is obtained
- oxytocin is introduced after the baseline monitoring by either nipple stimulation or IV pitocin
55
provides an early warning of fetal compromise
contraction stress test
56
contraindications for contraction stress test
- preterm labor
- placenta previa
- vasa previa
- cervical insufficiency
- multiple gestation
- previous classical incision for C/S
57
EFM to determine fetal well-being
nonstress test (NST)
- monitor for 20-30 minutes (unless baby is in a sleep cycle, then it may take longer)
- looking for 2, 15x15 accelerations in 20 min (on fetus >32weeks) or 10x10 (<32 weeks)
- documented as reactive or nonreactive
58
NST -> 2 accelerations in a 20min strip
reactive
59
method of evaluating fetal status
biophysical profiles
60
biophysical profile evaluates
- breathing movement
- gross body movement/muscle tone
- amniotic fluid index (volume)
- FHR
- NST
61
- baseline 110-160
- moderate variability
- no late and variable decels
- early decels
- accels may or may not be present
category 1 (normal)
62
- may include periodic brady/tachy
- minimal variablity
- marked variability
- no accels in response to stimulation
- recurrent variable or late decels with minimal or moderate variability
- prolonged decels >2min but <10min
category 2 (indeterminate aka equivocal or ambiguous data - not 1 or 3)
63
absent baseline variability and any of the following:
- recurrent late decels
- recurrent variable decels
- bradycardia
- sinusoidal pattern
category 3 (non-reassuring)
64
category 1 intervention
no action required
65
category 2 intervention
re-evaluate, further investigation
66
category 3 intervention
EVERYTHING
| - abnormal fetal acid-base status
67
FHM - regular smooth undulating wave-like pattern commonly seen with severe fetal anemia, chorioamnionitis, fetal sepsis, and administration of narcotic analgesics
sinusoidal FHR pattern
ALWAYS category 3
68
```
treatment of variable decelerations during labor
- or low amniotic fluid
treatment of (oligohydramnios)
```
amnioinfusion
69
infusion of room-temperature isotonic (normal saline, LR solution) fluid into the uterine cavity to relieve intermittent umbilical cord compression resulting in variable decels and transient fetal hypoxemia
amnioinfusion
70
amnioinfusion procedure
- review MD order
- membranes must be ruptured
- infused through IUPC
- use LR or normal saline
- warm fluid if ordered
- continuously monitor contraction intensity, duration, and resting tone as well as FHTs
- document
71
initiation of UC before their spontaneous onset for the purpose of bring about birth
induction
72
stimulation of UC after labor has started spontaneously yet progress proves unsatisfactory
augmentation
73
reasons for augmentation
- usually implemented for the management of hypotonic dysfunctional labor
- some practitioner believe active management of labor with pitocin augmentation lowers the incidence of c-sections
74
artificial rupture of the membranes
amniotomy
75
methods of induction and/or augmentation
- amniotomy (labor usually begins within 12hrs of rupture)
- nipple stimulation
- prostaglandins (prepidil, cervidil, cytotec) followed by oxytocin infusion
76
When an instrument with two curved blades is used to assist in the birth of the fetal head
forceps birth
77
indications for forceps birth
- a prolonged second stage of labor
| - the need to shorten the second stage of labor due to maternal and fetal complications
78
nursing care: forceps birth
obtain the type of forceps for the MD, the nurse may explain to the mother that the forceps will fit the same way two tablespoon fit around and egg.
- After the birth the nurse should assess the woman for vaginal or cervical lacerations, urinary retention, and hematoma formation in the pelvis soft tissues, which may result in from blood vessel damage.
- The infant should be assessed for bruising or abrasions at the site of blade application, facial palsy.
- Newborn and postpartum caregivers should be told that a forceps delivery ways performed.
79
Birth method involving the attachment of a vacuum cup to the fetal head using negative pressure to assist in the birth of the head
vacuum assisted birth
80
indications for vacuum assisted birth
same as for forceps delivery
- a prolonged second stage of labor
- the need to shorten the second stage of labor due to maternal and fetal complications
Used more often than forceps because easier to apply and the need for less anesthesia
81
vacuum assisted birth newborn risks
- cehalhematoma
- scalp lacerations
- subdural hematoma
82
vacuum assisted birth maternal risks
- perineal, vaginal, or cervical lacerations
| - soft tissue hematomas
83
vacuum assisted birth nursing care
Nurse should educate and provide support to the woman to remain active during labor, documentation, and make sure newborn and postpartum caregiver are informed of vacuum delivery
84
maternal indications for c-section
- specific cardiac diseases
- respiratory distress
- mechanical obstruction to the lower uterine segment
- history of previous c-section
85
fetal indications for c-section
- abnormal FHR or pattern
- malpresentation
- active maternal HSV
- maternal HIV
- congenital abnormalities
86
c-section complications
- aspiration
- hemorrhage
- atelectasis
- wound dehiscence/infection
- injury to bladder and bowel
87
TOLAC
trial of labor after cesarean section
88
VBAC
vaginal birth after c-section
89
criteria for VBAC
- one previous low-transverse cesarean birth
- clinically adequate pelvis
- no history of uterine rupture or uterine scars
- MD immediately available
- anesthesia available
