Exam 2 Flashcards
What monitor is used for Uterine Activity? “Internal and External”
Tocotransducer “toco”- placed on top of fundus (use gel)
Intrauterine Pressure Catheter (IUPC)- internal (inserted thru vagina)
What three things do you need to assess during a contraction?
○ Frequency
■ Start of one contraction to the start of another
■ Adequate active labor contractions are q2-5 minutes
■ Generally become more frequent in active labor q2-3 minutes
○ Duration
■ Start to finish of one contraction (last at least 40 seconds)
○ Strength
■ Depends on type of contraction monitoring
■ Can be palpated externally by placing a hand on the fundus during a contraction
● Classified as mild, moderate, or strong
■ Can only be measured with an internal contraction monitor (IUPC) (mmHg)
When would you use an IUPC (intrauterine pressure catheter)?
- Used with larger BMI
- Contraindicated in HIV Pos Patients
Fetal Heart Rate Monitoring Frequency Types
CONTINUOUS: remains on laboring person for the duration of labor
-External Monitor or Internal (more invasive)
INTERMITTENT: monitor every 15-60 minutes over one contraction
Where on the fetus are heart tones easiest to assess for a better fetal monitoring reading?
On the BACK of the fetus
What general quadrant on the maternal abdomen do you find fetal heart tones of a baby that is vertex? Breech?
Vertex: Lower Quadrant
Breech: Upper Quadrant
Internal Fetal ECG (rhythm vs just rate)Monitoring Types
Internal Fetal Electrode (IFE)
Fetal Scalp/spiral electrode (FSE)
Why would you do a fetal (ECG) internal monitor?
- Patient is moving a-lot and hard to get a tracing
- Fetal Intolerance requiring closer observation of the fetal heart pattern
- Maternal Habitus (extra fat)
- Contraindicated for HIV Positive Patients
What two steps in the labor process must be completed before any
internal monitors can be placed by a provider?
- Need to know baby is head down (vertex)
- ONLY if water is broken
Do contractions monitors need gel applied?
NO
Intermittent Auscultation
- One Benefit
- When to Assess Heart Rate
- When to NOT use
- Performed how frequently? (early labor, active labor, second stage)
- Benefit:
Freedom of movement for the laboring person
- When to Assess Heart Rate
Assess fetal heart rate BEFORE, DURING, and especially AFTER a contraction
- When to NOT use
Change to continuous monitoring if abnormalities detected
NOT option for high-risk pregnancies or patients receiving Pitocin
- Frequency:
EARLY- q30-60 minutes ACTIVE: q15-30 minutes SECOND STAGE: q5 minutes
Evidence shows that intermittent auscultation for low-risk labors is JUST AS effective as continuous monitoring and decreases risk of interventions (operative delivery/cesarean) (T/F)
True
Heart Rate Pattern Terminology: Used to describe frequency of accelerations/decelerations
● Intermittent (occasional)
● Recurrent (occurs with >50% of contractions)
● Periodic: (occurs as part of a pattern)
Definition of resting tone and nadir:
Characteristics of a fetal heart tracing…
● Resting tone: period of rest between contractions
● Nadir: lowest point of a fetal heart rate deceleration
Fetal Compromise-
Definition of Hypoxemia, Hypoxia, Acidemia
● Hypoxemia: decreased oxygen in fetal blood
● Hypoxia: decreased oxygen in fetal tissues
● Acidemia: severe enough oxygen deprivation leading to a drop in pH
What should be done if the nurse notices a client is contracting every 2 minutes?
- Decrease Oxytocin if on medication
- Give IV bolus (if super dehydrated contractions can become worse)
Baseline Fetal Heart Rate: Definition, Normal Rate
Definition:
● Average heart rate (beats per minute) OVER 10 MINUTES
Rate:
● Normal: 110-160
*NOTE: This is the first assessment that should be determined on a heart rate monitor
Fetal Tachycardia: rate and causes
Rate: (>160 bpm)
Causes:
○ Infection, maternal fever, early hypoxemia, illicit
drugs/some medications or maternal conditions
Fetal Bradycardia: rate and causes
Rate: (<110 bpm)
Causes:
○Medications like Narcotics and Magnesium Sulfate,
cardiac anomalies, maternal hyPOthermia
What should be the nurse’s first intervention if a monitor is placed
and the fetal heart rate detected in the 90’s?
Compare to mother’s pulse
What is variability?
What is the difference in rate between: Marked, Moderate, Minimal, and Absent:
It the average fluctuations of the heart rate (beats to beat)
- Marked (> 25bpm) SELDOM SEEN,
- Moderate (6-25bpm) IDEAL
Minimal (1-5bpm) Potential sign of fetal distress
- Absent (flat line)- Very concerning- NEED to deliver
- *Note: variability is the best indicator of fetal oxygenation status*
What situations/medications might cause a decrease in heart rate?
● Temporary decreases in variability can be normal: S_leep Cycles_ of ~10
minutes, Narcotics and Magnesium Sulfate
Acceleration
● Transient increase in heart rate of 15 beats per minute (bpm) above the baseline
lasting at least 15 seconds
Deceleration and Types
● Transient decreases in heart rate from the baseline
● Can be associated with a contraction or unrelated
Types:
● Early deceleration
● Variable deceleration
● Late deceleration
● Prolonged deceleration
Early Decelerations
● U-shaped curved decelerations
● Always occur with contractions
● Occur due to fetal head compression
● Benign
● No interventions necessary
Variable Decelerations (DIFFERENT THAN VARIABILITY)
● V-shaped decelerations that take <30 seconds to get to the nadir (lowest part)
● Abrupt drop in heart rate from baseline
● Occurs due to umbilical cord compression
● Benign if small and transient, abnormal if repetitive and large
● Can be related or unrelated to contractions
What intervention would likely be most helpful for variable decelerations?
Change maternal position: hopefully relieves pressure off of umbilical cord
Late Decelerations
● Decelerations that take >30 seconds to get to the nadir
● Decrease in heart rate where the nadir occurs AFTER the peak of a contraction
● Sign of fetal hypoxemia due to placental insufficiency
● More concerning
Would we offer food or liquids to a client with repetitive late decelerations?
No: potential c-section
Reasons for decelerations: VEALCHOP
Variable———————–Cord Compression
Early—————————-Head Compression
Accelerations—————-Okay or Good
Late—————————–Placental Insufficiency
Prolonged Deceleration Length
● Drop in heart rate that lasts longer than 2 minutes
● Suggests poor fetal reserve
Prolonged Deceleration Nursing Interventions:
● First! Start performing intrauterine resuscitation
● If no improvement within 1-2 minutes, must elicit help
How long can a fetus maintain perfusion if deprived of oxygen
before suffering long-term consequences?
Around 12 min
Intrauterine Resuscitation: Interventions
● First intervention on the NCLEX is to turn off any IV Pitocin
● Reposition
● Start IV fluid bolus
● Assess maternal blood pressure
● Assess uterine contraction pattern
● Call for assistance
● Consider cervical exam
● Potentially prepare for urgent/emergent delivery
NICHD Categories of Fetal Heart Rate Monitoring
● Category 1-Good
○ Defined as: Normal baseline, moderate variability, +/- accelerations, - decelerations
(except early decelerations are okay)
● Category 2: ALL OTHERS (majority of tracings)
○ Defined as: All tracings that do not fall into category 1 or 3
○ Outcome: Continue to perform intrauterine resuscitation if needed and monitor
● Category 3-Bad
○ Defined as: absent variability with recurrent late or early decelerations AND/OR
bradycardia
For both Contraction Stress Test (CST) & Vibroacoustic stimulation (VAS) Pos vs. Neg test
Positive test: Not reassuring (decelerations with contractions/sound)
Negative test: reassuring (no decelerations)
Contraction stress test (CST)
-Create contractions by administering Oxytocin
○ Requires 3 contractions lasting at least 40 seconds to occur in a 10 minute period to offer accurate results
What do you do with a positive CST or VAS
result?
Assess further and do an ultra sound called a (BPP)
What is a Vibroacoustic stimulation (VAS)
Assesses fetal response to a loud noise
BPP (Biophysical Profile) Ultrasound
● Detailed ultrasound assessment to assess fetal well-being
● Gives more information than a non-stress test alone and helps determine fetal
well-being
● May help in determining if a fetus should be delivered or not
● Assesses fetal movement, fetal breathing, fetal tone & amniotic fluid volume
● Score is out of 10
○ 8 points from ultrasound
○ 2 points from nonstress test
● No odd points are awarded
○ Score is either 0 or 2 for each criteria
Nonstress Test (NST)
● Most common form of fetal surveillance; easy and noninvasive
● 20 minute fetal heart tracing
● Good predictor of fetal well-being if reassuring
● High risk pregnancies may have monthly, weekly, or even daily NSTs scheduled
Criteria for Nonstress Test (NST): Reactive vs Non-reactive
● Must have at least 2 accelerations and no decelerations in 20 minute period (except
early decelerations are okay)○ Reactive = reassuring (criteria met)
● If have not met criteria after 20 minutes:○ Continue to watch for another 40 minutes
● If have not met criteria after 1 hour:○ Non-reactive = non-reassuring (criteria not met)
○ Would then need more information → send for Biophysical profile ultrasound (BPP)
Cesarean Births: categorization for one or more C-sections
What type of incision allows for potential vaginal delivery later?
1/3 pregnant patients deliver via cesarean
Primary: first cesarean
Repeat: more than one first cesarean
Ideally you want horizontal incision
What type of incision will force you to ALWAYS deliver via c-section?
VERTICAL incision on abdomen or uterus (NEVER labor again)!!!!!!!!!!
Indications for Cesarean Births
- History of any uterine surgery
- Placental abnormality
- Active Herpes Lesions
- Fetal Malposition (BREECH)
- Multiple Gestations
- Maternal Medication Condition
Types of monitoring for high-risk pregnancies
-Diagnostic Genetic Testing:
*Amniocentesis or Chorionic Villus Sampling (CVS)
-Nonstress Test (NST), Contraction Stress Test (CST), Vibroacoustic Stimulation Test (VAS)
-Additional Ultrasounds:
*Biophysical Profile (BPP)
What risk do Cesarean Sections have on babies?
Respiratory Distress
What is external Cephalic Version (ECV)? What are the risks?
Turns a baby from a breech or transverse to a vertex position
-Externally rotated on abdomen (epidural recommended)
Performed by 1-2 doctors at the same time and ultrasound assess
Risks: Fetal distress or Placental abruptions
At what gestational age do we think it would be best to try to rotate a breech baby?
37 weeks
What is Amniocentesis (“Amnio”)?
Indications?
● Amniotic fluid (contains fetal cells) drawn up in a syringe via needle into the uterus after 14 weeks
● Indications: diagnosis of aneuploidy or anomalies, assess fetal lung maturity, fetal blood typing
What is Chorionic Villus Sampling (CVS)?
● Transcervical or transabdominal biopsy of the fetal part of the placenta after 10 weeks
● Similar indications as amnio
Nursing interventions for External Cephalic Version (ECV)
- Administer tocolytic Terbutaline BEFORE procedure to relax uterus
- Trace fetal heart rate before and after procedure, education, documentation
*DO NOT ATTEMPT until uterus is relaxed: how do you know? heart rate increases from terbutaline
VTOL/TOLAC vs VBAC
- *ATTEMPT** to deliver vaginal after Cesarean (VTOL OR TOLAC)
- -Vaginal trial of labor (VTOL)*
- -Trial of labor after Cesarean (TOLAC)*
- *SUCCESS**: (VBAC)
- -vaginal birth after cesarean (VBAC)*
Contraindication for VTOL OR TOLAC
- Vertical incisions
- Abnormal fetal presentation (breech)
- Multiples
What is a complication for a vaginal delivery after cesarean?
Uterine Rupture but RARE
Two types of pain in labor?
Visceral Pain and Somatic Pain
Visceral Pain
● Pain from uterine and cervical nerves, stretching og of
cervical tissue, distension of uterine muscle, pressure on
nearby organs and nerves, ischemia from disruption in
uterine blood flow with contractions ○ Includes referred pain
○ 1st stage of labor
Somatic Pain
● Pain from pressure on perineum and against nearby
bladder and rectum; lacerations
○ Often note a decrease in pain intensity
○ “Ring of fire” is not always reported
Why don’t we want to give narcotics close to delivery?
Can pass to baby
What is Nitrous? What does it do? How is it administered?
● 50% oxygen, 50% nitrous
● Self-administered via facemask
● Short half-life so rare side effects to patient or baby
● Does not reduce pain intensity but reduces pain perception
Local Anesthesia: used for what?
Provides coverage for a specific area: mostly used for laceration repairs or doesn’t want to feel crowning
Difference between regional epidural vs General anesthesia
Regional does not effect cognitive- mother still awake
General anesthesia is used for emergencies- baby is at risk for respiratory depression cause additional meds are given to mom: goal is deliver FAST so baby is exposed least amount of time
Side Effects of Epidural
- Hypotension (#1 side effect and expect it)
- itching
- back soreness
rare-spinal headache
Nursing intervention for Epidural side effect: Hypotension
- GIVE a fluid bolus in anticipation
- Assess vitals VERY often 2-5 min
What is a bishop’s score done by provider? Above and below 8 indications:
If score is below 8 then cervical ripening is needed
* have to use chemical methods (both prostaglandins that cause mild contractions)
*mechanical methods just force cervix to dilate (balloon or laminara)
If score is above 8- then you can go straight to inductions and start oxytocin
Augmentation (used to speed up labor)
-Chemical : oxytocin
- Mechanical or physical:
- sex or nipple stimulation
- membrane stripping
- artificial rupture of membranes
Nurses Role with Synthetic oxytocin
- Monitor fetal heart rate
- manage oxytocin titration based on uterine activity
- document
- educate
When is synthetic oxytocin contraindicated?
tachysystole, non-reassuring fetal heart tracing
Amniotomy:
process of breaking water by a provider
○ Must be at least a little dilated
○ Use of an amnihook to snag bag of water
often used to speed up labor process
Nurse Role with Amniotomy
- Assess fetal heart rate before and after,
- Assist with linen change
- check temperature q1 hour afterwards (risk of infection)
- education
- document