exam 2 fetal adaptation

Question 1

What is associated with fetal circulation?

Answer 1

2 arteries
1 veins
While the fetus is in utero the 2 arteries carry deoxygenated blood from the fetus to the placenta and the umbilical vein carries oxygenated blood to the fetus
Adequate oxygenation promotes normal function of the autonomic nervous system, enabling the fetus to adapt to the stress of labor.

Question 2

what are the types of monitoring?

Answer 2

Auscultation/Intermittent Auscultation
External Fetal Monitoring
Internal Fetal Monitoring

Question 3

external vs. internal monitoring:

Answer 3

External monitoring
U/S (Ultrasound Transducer) for Fetal monitoring
TOCO (Tocotransducer) for Maternal monitoring (Electronic Monitoring: non-invasive (External) continuous and 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 ctx. Allows the nursing staff to watch more than 1 mother at time. Can be used if mother’s bags of water are ruptured or not. Allows for internal monitoring to be available if ROM.
Disadvantages: restricts movement. Can loss contact with maternal or fetal m movement. Can half or double the rate. Difficulty with obese patients. Ctx must be palpated.)

Internal Monitoring
ISE (Internal Scalp Electrode) for Fetal Monitoring
IUPC (Intrauterine Pressure Catheter) for Maternal Monitoring

Question 4

what is important to note on a monitoring strip?

Answer 4

Top = Fetal Heart Rate
Bottom = Uterine Activity
Each vertical dark red line = 1 minute
Each lighter vertical line = 10 seconds
6 columns of 10 seconds = 1 minute

Question 5

Beginning of one contraction to the beginning of the next contraction. Measured in minutes.

Answer 5

frequency

Question 6

Beginning of the contraction to the end of contraction. Measured in seconds.

Answer 6

duration

Question 7

how strong the contraction feels upon palpation
(mild moderate or strong)
may also be measured by internal uterine pressure cath (measured in mmHg)

Answer 7

intensity

Question 8

Palpation of uterus when no contraction is taking place.

Answer 8

resting tone

Question 9

what are MVUs?

Answer 9

MVUs = Montevideo Units
Calculated by subtracting the baseline during resting tone and the pressure from the peak for each contraction in a 10-minute strip. Then add those units up.
During 1st stage of labor range from 100 to 250
During 2nd stage of labor range from 300-400
Contraction intensities of 40 mmhg or more AND MVUs of 80-120 are generally sufficient to initiate spontaneous labor

A unit of measure indicating the intensity of uterine contractions in millimeters of mercury (mmHg)
Only expressed when using an Intrauterine Pressure Catheter (IUPC)
The Contraction intensity minus the resting tone times the number of contractions in 10 minutes

Question 10

FHR greater than 160 BPM lasting greater than 10 mins.

Answer 10

tachycardia

Tachycardia causes = early fetal hypoxemia, maternal fever, maternal dehydration, drug induced (atropine, hydroxyzine (Vistaril), Terbutaline (Brethine) ritodrine, cocaine, methamphetamines), Intraamniotic infection, maternal hyperthyroidism, fetal anemia, fetal heart failure, fetal cardiac dysrhythmias

Question 11

FHR less than 110 BPM lasting greater than 10 mins.

Answer 11

bradycardia

Bradycardia causes = late fetal hypoxemia.hypoxia, drug induced (MgSO4,propranolol, anesthetics, epidural, stadol), prolonged umbilical cord compression, fetal congenital heart block, maternal hypothermia, prolonged maternal hypoglycemia, last sign of hypoxia. Must watch bradycardia closely to differentiate between bradycardia and a prolonged deceleration.

Question 12

what is variability?

Answer 12

fluctuation in the baseline FHR:
absent: undetectable
minimal: <5 bpm
moderate: 6-25 bpm
marked >25 bpm

Variability:
- The normal irregularity of cardiac rhythm resulting from a continuous balancing interaction of the sympathetic (cardio-acceleration) and parasympathetic (cardio-deceleration) branches of the autonomic nervous system
- Expected irregular fluctuations of the baseline that are indicators of fetal well being. The etchiness of the tracing when evaluating the baseline. When watching the monitor you can see the fluctuations by watching the numbers correlate with the tracing on the paper
- 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 less than 28 weeks, hypoxia, fetal anomalies

most important FHR characteristic – absence is considered non-reassuring

indicates ability of fetus to neurologically modulate FHR in response to oxygen needs

Absence of variability is demonstrated by a smooth or flat baseline

Question 13

what are periodic changes?

Answer 13

in fetal heart rate are transient changes (accels or decels) from baseline occurring in response to uterine contractions.
Late and early decelerations are always periodic

Question 14

what are episodic changes?

Answer 14

accelerations or decelerations that occur without any specific relationship to uterine activity.

Variable decelerations and accelerations can be both periodic and episodic

Question 15

what are accelerations?

Answer 15

Defined as: An abrupt, temporary increase in the FHR that peaks at least 15 BPM above the baseline and lasts at least 15 seconds. (For fetus = 33 weeks or greater)

if 32 weeks: 10 BPM above the baseline and lasting 10 seconds is acceptable

Prolonged acceleration is when the acceleration lasts longer than 2 minutes, but less than 10 minutes.

If longer than 10 minutes, the baseline has now changed

Question 16

what is the etiology for accelerations?

Answer 16

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 REASSURRING!

Question 17

what are early decelerations?

Answer 17

Early: looks like a mirror image of a contraction, gradual descent from baseline and returns to base line by the end of the contraction. Must be periodic.
Cause
Head Compression  reflex vagal response c resultant slowing of FHR during the UC.
NOT associated with fetal compromise and require NO intervention

Question 18

what are variable decelerations?

Answer 18

Variable: Abrupt rise and fall from the baseline. Looks like a “V” or “W”.
The decrease in heart rate is at least 15 BPM and lasts at least 15 seconds, but less than 2 minutes.
Cord Compression
Can be periodic or Non-periodic (Episodic)
Short cord
Knot in cord
Prolapsed cord = emergency situation

Question 19

what are late decelerations?

Answer 19

Late: Fetal heart rate decreases often at the peak of the contraction and returns to baseline after the contraction has already ended. Must be Periodic. There is an impairment of placental/oxygen exchange
Uteroplacental insufficiency
Maternal Hypotension/hypertension
Diabetes
Decrease in fetal oxygen reserves

Question 20

what are the BIG 5 interventions late decels?

Answer 20

1. Evaluate the pattern.
2. Identify the cause.
3. Stop Oxytocin Remove the Pitocin
4. Turn the patient or Reposition the patient.
5. O2 per facemask – 8-10 L/min. Re-oxygenate
6. IV fluids or fluid bolus. Rehydrate
7. Initiate continuous monitoring.
8. Call physician Report to the health care provider . Turning the pt = especially cord compression, Never place pt in supine position – always wedge. Decreases pressure on the heart from the uterus = allowing better oxygenation to go to the placenta. Increase fluid helps expand the maternal blood volume = improving placental infusion. O2 increases blood oxygen saturation, making more oxygen available to the fetus.

May also consider elevating her legs if hypotensive, palpating the uterus if Tachysystole (Ctx closer than 2 minutes apart) is suspected, internal monitoring, and/or assisting with the birth if not corrected

Question 21

what does VEAL CHOP MINE mean?

Answer 21

VEAL: pattern
variable decel
early decel
acceleration
late decel

CHOP: cause
cord compression (variable decels)
head compression (early decels)
oxygenation (accels)
placental/uterine insufficiency (late decels)

MINE: action
move the pt (variable decels)
investigate if delivery is coming (early decels)
nothing this is a good sign (accelerations)
everything (late decels)

Question 22

Contraction Stress Test AKA Oxytocin Challenge Test?

Answer 22

Electronic fetal monitoring used to see how the fetus responds to contractions.
It provides an early warning of fetal compromise
Contractions decrease uterine blood flow and placental perfusion. If this decrease is sufficient to produce hypoxia in the fetus a deceleration in FHR results.
A 10-20 minute baseline is obtained,
Oxytocin is introduced after the baseline monitoring by either nipple stimulation or IV Pitocin

Question 23

CST or OCT Interpretation?

Answer 23

Negative
Positive
Suspicious or Equivocal
Equivocal-Hyperstimulatory
Unsatisfactory

For test purposes only know if negative or Positive

Question 24

NST?

Answer 24

Electronic Fetal monitoring to determine fetal well-being
Monitor for 20-30 minutes unless baby is in a sleep cycle then it may take longer
Looking for 2 15 x15 accelerations in 20 minutes (on fetus greater than 32 weeks gestation) If less than 32 weeks 2 10x10 accelerations
Documented as Reactive or Non-reactive

Non-reactive test does not demonstrate the 2 accelerations within 20 minutes.

Do not get reactive and non-reactive mixed up with reassuring and non-reassuring. These have to do with looking at the fetal monitor strip for longer periods of time to evaluate the fetus in all aspects. ReassuringFHRpatternsinclude a baseline FHR in thenormalrange of 110-160 bpm, moderate variability, accelerations withfetalmovement, and the absence of nonreassuring signs.
Reactive is only looking for accelerations in a 20 minute strip

In essence you can have a reassuring strip that is non-reactive. Baseline of 110-160, moderate variability, no decelerations, no accelerations and baby is moving around.

Question 25

Biophysical profiles?

Answer 25

Method of evaluating fetal status
Breathing movement
Gross body movement/muscle tone
Amniotic Fluid Index (volume)
Fetal Heart Rate
NST

Ultra sound will give info on the 1st 4, Worth 2 points apiece. Receives 2 points for strip according to FHR and reaction to ctx AKA NST. Total points 10/10

Question 26

Category 1?

Answer 26

normal
no action required

Baseline: 110-160 bpm
Moderate variability

No Late or Variable decels,

+/- Early decels,
+/- Accels

Question 27

category 2?

Answer 27

Not predictive of abnormal fetal acid base status but can’t categorize I or III
Re-evaluate, intra-utero tx and con’t surveillance

Everything not categorized as Category I or III

Examples :
Tachy, Brady with normal variability

Absent, minimal, or
marked variability

Lates + mod variability,
unusual variables

Question 28

category 3?

Answer 28

Abnormal fetal
acid-base status
Action required!!

Absent variability, plus either…..
Recurrent late/variable decels,
Bradycardia
Sinusoidal pattern

Question 29

category 3?

Answer 29

Abnormal fetal
acid-base status
Action required!!

Absent variability, plus either…..
Recurrent late/variable decels,
Bradycardia
Sinusoidal pattern

Question 30

what is a amnioinfusion?

Answer 30

Infusion of room-temperature isotonic (normal saline, lactated Ringer’s solution) fluid into the uterine cavity to relieve intermittent umbilical cord compression resulting in in variable decelerations and transient fetal hypoxemia.

Purpose:
Treatment of Variable Decels
Low amniotic fluid

Amnioinfusion is performed:
Treatment of variable decelerations during labor. The purpose is to treat oligohydramnios and provide cushion for the umbilical cord
Dilute moderate to thick meconium-stained amniotic fluid to avoid aspiration syndrome, no longer recommended.

Procedure:
Review MD order
Membranes must be ruptured
Infused through and IUPC
Use either Lactated Ringsers or Normal Saline
Warm fluid if ordered
Continuously monitor contraction intensity,duration, and resting tone, as well as FHTs
Document

Question 31

What is the difference between induction and augmentation?

Answer 31

Induction is the initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth.
Augmentation is the stimulation of uterine contractions after labor has started spontaneously yet progress proves unsatisfactory

Question 32

Why do we augment?

Answer 32

Usually implemented for the management of hypotonic dysfunctional labor.
Some providers believe active management of labor with pitocin augmentation lowers the incidence of c-section

Question 33

Methods of Induction and/or augmentation:

Answer 33

amniotomy – artificial rupture of the membranes can be used to stimulate labor when the condition of the cervix is favorable. Labor usually begins within 12 hours of rupture. Amniotomy within 1 hour of admission of a woman in labor is part of active management of labor. [AROM places the presenting part in direct contact with the cervix]

Nipple stimulation – stimulates release of oxytocin. May be used as a method of contraction stress testing

prostaglandins – used to ripen the cervix by softening and thinning it. Examples – Prepidil, Cervidil, Cytotec. Followed by oxytocin infusion (naturally secreted by pituitary; pitocin is the synthetic version)

Question 34

When an instrument with two curved blades is used to assist in the birth of the fetal head. Indications for use include a prolonged second stage of labor and the need to shorten the second stage of labor due to maternal and fetal complications.

Answer 34

Forceps

Nursing care – 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.

Question 35

Birth method involving the attachment of a vacuum cup to the fetal head using negative pressure to assist in the birth of the head. Indications are the same for a forceps delivery. Used more often than forceps because easier to apply and the need for less anesthesia. Risk for newborn include cehalhematoma, scalp lacerations, and subdural hematoma. Maternal risk include perineal, vaginal, or cervical lacerations and soft tissue hematomas. 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.

Answer 35

vacuum assisted

Question 36

what is important to know for a cesarean birth?

Answer 36

planned, unplanned, elective
surgical tech
complicaions
anesthesia

C-section- Birth of the fetus through trans abdominal incision of the uterus. May be planned, unplanned, or elective

Maternal- Specific cardiac disease, respiratoty distress, mechanical obstruction to the lower uterine segment, hx of previous c-section

Fetal- abnormal FHR or pattern, malpresentattion, active maternal HSV, maternal HIV, congenital abnormities

Maternal-fetal- dysfunction labor, placenta abruption, placenta previa, elective c-section.

Surgical Techniques
Skin -horizontal or vertical
Uterine incision- Low transverse, low vertical, classic

Complications- aspiration, hemorrage, atelectasis, wound dehiscence/infection, injury to bladder and bowel.

Anesthesia- spinal, epidural, general anesthesia
Intraoperative care- Nurse acts as circulator or scrub nurse, Nurse present for newborn
Immediate postoperative care- Women will go to PACU (Vital signs, maintenance of airway, incisional dressing, fundus, and lochia)

Question 37

TOLAC vs VBAC?

Answer 37

Approximately 70%-80% success rate
Vaginal delivery after cesarean criteria
One previous low-transverse cesarean birth
Clinically adequate pelvis
No hx of uterine rupture or uterine scars
MD immediately available
Anesthesia available

TOLAC is a trial of labor after cesarean section
VBAC is vaginal BIRTH after C/section
A woman who delivers vaginally after a previous c/section delivery can be called a successful VBAC. If she has to have a repeat C/Section, but tried to deliver vaginally is an unsuccessful VBAC that had a Trial of Labor (TOLAC)