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OB > exam two: fetal monitoring > Flashcards

exam two: fetal monitoring Flashcards

1
Q

influences on fetal heart rate

A
  1. CNS: regulator of the autonomic nervous system which takes awhile to fully develop
  2. Autonomic nervous system:
    - parasympathetic nervous system
    - sympathetic nervous system
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2
Q

when is the autonomic nervous system fully developed

A
  • 32 weeks
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3
Q

influences on the fetal heart rate: parasympathetic nervous system

A
  • vagus nerve stimulation slows FHR
  • pressure on fetal head (fontanelles) stimulates this parasympathetic response
  • may also stimulate passage of meconium
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4
Q

influences on the fetal heart rate: sympathetic nervous system

A
  • stimulation increases FHR and strength of heart contraction
  • stimulated by loud noises, vibration, stimulation of scalp or pressure on maternal abdomen
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5
Q

Fetal autonomic nervous system is sensitive to changes in

A
  • 02 exchange
  • carbon dioxide production
  • blood pressure changes
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6
Q

chemoreceptors

A
  • located in carotid arch and CNS
  • respond to changes in fetal 02, co2, ph levels
  • stimulation results in either speeding up or slowing down HR
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7
Q

Baroreceptors

A
  • located in carotid and aortic arch
  • detect pressure changes
  • stimulation results in vasodilation, decreased BP, and reflective increase in HR
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8
Q

fetal reserves

A
  • reserves o2 available to fetus to withstand transient changes in blood flow during labor
  • not much reserves = wont do well withstanding changes
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9
Q

utero placental unit

A
  • ability to transfer oxygen to fetus and remove waste products (perfusion of placenta)
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10
Q

factors affecting fetal perfusion

A
  • maternal HTN/hypotension
  • ablution of placenta: part of the placenta separates before birth= decreased perfusion
  • diabetes: vasoconstriction
  • smoking: vasoconstriction and calcification to placenta= affects ability of placenta to perfuse fetus
  • substance abuse: coccaine especially= abruption
  • maternal supine position: hypotension
  • post term pregnancy: placenta has shelf life and post this = decreased perfusion
  • uterine tachysystole: too frequent contractions (more than 5 in 10 minutes)
  • cord compression: compressed = blood cant flow from placenta to fetus
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11
Q

normal healthy fetus and repetitive contractions

A
  • will have enough reserves to tolerate repetitive contractions (no perfusion)
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12
Q

too frequent or too long contractions

A
  • decrease perfusion because there isnt enough time to recover (absorb o2) between contractions
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13
Q

poor maternal oxygenation

A
  • impacts fetus by not providing enough 02 to the placenta
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14
Q

coord compression

A
  • decreases ability to transfer 02 to fetus
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15
Q

problems from 02 transfer occur where

A
  • placenta
  • uterus
  • maternal perfusion
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16
Q

contractions and their affect on flow

A
  • before contraction: normal flow
  • as contraction occurs: reduced flow
  • peak of contraction: no blood flow into uterus
  • as contraction resolves: reduced blood flow
  • as contraction is finished: normal flow
  • if too frequently these contractions occur: not enough time for baby to recover
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17
Q

results of decreased placental perfusion

A
  • normal oxygenation in fetus&raquo_space; something occurs that decreases 02 available&raquo_space; hypoxemia (decreased o2 in blood)&raquo_space; blood flow shunted to vital organs&raquo_space; tissue hypoxia&raquo_space; increase in lactic acid&raquo_space; anaerobic metabolism in tissues&raquo_space; metabolic acidosis = decreased tissue ph&raquo_space; injury or death
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18
Q

guidelines for assessment

A
  • know your hospitals guidelines
  • may need to assess more frequently
  • intermittent assessment is as appropriate in low risk pt as continuous EFM
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19
Q

high risk monitoring

A
  • 1 st stage:q 15 minutes
  • 2nd stage: Q 5 minutes
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20
Q

low risk monitoring

A
  • 1st stage: Q 30 minutes
    -2nd stage: Q 15 minutes
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21
Q

methods for FHR assessment

A

-Intermittent auscultation with doppler or fetoscope
-External ultrasound transducer
-Fetal spiral electrode (FSE)- internal

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22
Q

methods for contraction assessment

A
  • Palpation
  • External tocodynomometer “Toco”
  • Intrauterine pressure catheter (IUPC)- internal
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23
Q

normal contraction

A
  • 5 contractions or less in 10 minutes averaged over 30 minutes
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24
Q

tachysystole contractions

A
  • more than 5 contractions in 10 minute period averaged over 30 minutes
  • causes decreased perfusion to fetus
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25
Q

Intermittent Auscultation (IA) & Palpation of Contractions

A

-May be used for assessment especially in low risk women
- use doppler and fetoscope
-Requires 1:1 nurse-patient ratio and proper technique
-Follows low risk guidelines (q 30 min & q 15min)
-FHR assessed before, during and after contractions

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26
Q

benefits to Intermittent Auscultation (IA) & Palpation of Contractions

A
  • non invasive
  • doesnt tie the woman to a monitor
  • increased hands on pt care
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27
Q

disadvantages to to Intermittent Auscultation (IA) & Palpation of Contractions

A
  • no permenant record
  • maternal size and position can inhibit ability to auscultate FHR and palpation of contractions
  • difficult to assess uterine pressure quantitatively
  • time intensive
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28
Q

contraction palpation

A
  1. Frequency (minutes) onset of one contraction to
    onset of the next contraction
  2. Duration(seconds) length of one contraction from beginning to end
  3. Intensity
    -Mild: pressing on nose
    -Moderate: compressing on chin
    -Strong: compressing on forehead
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29
Q

interval between red lines

A

1 minute

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30
Q

interval between pink lines

A

10 seconds

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31
Q

FHR tracking (BPM)

A

5-10 BEAT increments

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32
Q

external monitors

A
  1. Ultrasound transducer: placed on lower abdomen
  2. Tocodynomometer or Tocotransducer or “Toco”
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33
Q

Ultrasound transducer

A
  • external
  • water soluble gel used to help conduct sound waves
    -Measures FHR by reflecting high frequency sound waves off the movement of the fetal heart valves
    -Placement: over the area of maximum intensity (fetal back)
    -Compare rate to maternal pulse to make sure not picking up moms pulse
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34
Q

Tocodynomometer or Tocotransducer or “Toco”

A
  • external
  • upper abdomen
  • measures; frequency and duration of uterine contractions
  • doesn’t measure intensity: need to palpate for this
  • placed on the fundus
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35
Q

contractions external measurements

A
  1. duration: beginning to end
  2. frequency: beginning to beginning
  3. intensity: by palpation- mild, moderate, strong
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36
Q

Internal Fetal Heart Monitor

A

-Fetal spiral electrode (FSE)
-Measures FHR by reading fetal ECG
-Fine wire placed under skin of
presenting part
-Require ruptured membranes and cervical dilation (1-2 cm)

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37
Q

benefits to fetal spiral electrode (internal monitor)

A
  • more accurate picture of HR
  • not affected by movement
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38
Q

disadvantages to fetal spiral electrode (internal monitor)

A
  • invasive
  • risk of infection
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39
Q

Internal Contraction Monitor

A

-Intrauterine pressure catheter (IUPC)
-Measures pressure in the uterus in mmHG
-Measures: frequency and duration, resting tone (tone of uterus between contractions= tension in uterus between contractions), intensity of contractions
-Placed in uterus alongside the fetus to the fundus
-Used for: to evaluate effectiveness of contractions and amnioinfusion = putting fluid back into the uterus because too little (cushions umbilical cord)

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40
Q

calculating intensity

A
  • reported in Montevideo Units (MVUs)
  • these represent the total of the intensity of each contraction in a 10 minute period
  • MVUs > 200 = labor can progress (90% of labors)
  • baseline pressure needs to be subtracted from each reading
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41
Q

FHR baseline

A
  • this is the first component to be evaluated
  • Mean FHR during 10 minute period rounded to the nearest 5 bpm
  • exclude accelerations and decelerations
  • must observe for 2 minutes of the 10 minute period (doesn’t have to be consecutive thought can be 1 minute at the begging and one minute at the end)
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42
Q

Normal FHR

A

110-160
- decreases with gestational age as the heart gets bigger

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43
Q

bradycardia

A
  • < 110 bpm for at least 10 minutes
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44
Q

causes of bradycardia

A
  • vagal nerve stimulation (baby suddenly drops down into the pelvis)
  • Drugs
  • maternal hypotension (epidural)
  • fetal hypoxia
45
Q

tachycardia

A
  • > 160 bpm for at least 10 minutes
46
Q

maternal causes of tachycardia

A
  • fever
  • dehydration
  • meds/drugs
  • infection
  • anemia
47
Q

fetal causes of tachycardia

A
  • infection
  • activity
  • compensation after acute hypoxemia
  • chronic hypoxemia
  • cardiac abnormalaites
  • tachyarrhythmias
  • anemia
48
Q

signs that tachycardia is non reassuring with other FHR patterns

A
  • absent or minimal variability
  • late or severe variable decelerations
49
Q

baseline variability

A
  • most important predictor of adequate fetal oxygenation
  • reflects a well functioning nervous system
  • visible regular fluctuations in FHR above and below the baseline FHR (two or more cycles per minute, assessed between any FHR changes)
  • categories: absent, minimal, moderate, marked
50
Q

absent variability

A
  • variation in amplitude is undetectabale above or below the baseline
  • flat line
  • MAY BE CONCERNING
51
Q

causes of absent variability

A
  • fetal sleep
  • medication effects
  • fetal hypoxia and acidosis
52
Q

minimal variability

A
  • variation in HR changes detectable but </= 5 bpm
  • caused by the same thing as absent
  • may be concerning
53
Q

moderate variability

A
  • amplitude range of: 6-25 bpm above and below
  • highly predictive of: absence of metabolic acidemia
  • happy baby
54
Q

marked variability

A
  • range in FHR is > 25 bpm from top # and bottom #
  • unable to establish a baseline (there is no time period of 2 minutes of one FHR)
  • caused by: early or mild hypoxia, fetal activity, or medications/drug effects
55
Q

sinusoidal

A
  • not very common
  • smooth, regular, wavelike pattern (looks like letter s on its side)
  • amplitude of 5-15 bpm and occurs 3-5 times in 1 minute lasting for 20 minutes or more
  • benign or pathologic
56
Q

benign sinusoidal

A
  • not as smooth appearing
  • caused by fetal sucking or medications
57
Q

pathologic sinusoidal

A
  • non- reassuring finding
  • causes: anemia, chronic fetal bleeding, CNS malformation, twin-twin transfusion syndrome, isoimmunization of fetus, cord occlusion
58
Q

twin-twin transfusion syndrome

A
  • connection between the placentas and one twin give the other a bunch of blood
  • the donor twin will have this issue
59
Q

FHR changes

A
  • may occur with or without contractions
  • with = periodic
  • without = episodic
  • can include accelerations or decelerations
  • decelerations with all types for periodic
  • decelerations with variables for episodic
60
Q

accelerations

A
  • abrupt increase above baseline
  • onset to peak of increase < 30 seconds
  • for pregnancies >/= 32 weeks: ACME of >/= 15 bpm for >/= 15 seconds from beginning to end of the increase
  • for pregnancies < 32 weeks: ACME of >/= 10 bpm for >/= 10 seconds
  • identify a well oxygenated fetus and the absence of acidemia
61
Q

prolonged accelerations

A
  • > /= 2 minutes and </= 10 minutes (2-10 minutes)
  • if greater than 10 minutes its no longer an acceleration but baseline FHR change
62
Q

decelerations

A
  • transitory decrease in FHR below baseline
  • abrupt: onset to nadir (bottom point) = < 30 seconds
  • gradual: onset to nadir = >/= 30 seconds
63
Q

abrupt deceleration

A

variable deceleration with or without contractions

64
Q

gradual deceleration

A
  1. early deceleration during contractions
  2. late deceleration after contractions
65
Q

variable decelerations

A
  • ABRUPT decrease in FHR
  • most common deceleration in labor
  • > /= 15 bpm lasting >/= 15 seconds but < 2 minutes
  • vary in shape, depth, duration, and position
66
Q

variable decelerations relationship with contractions

A
  • with or without contractions
  • with every contraction or at anytime between contraction or after contraction
67
Q

variable decelerations caused by

A
  • cord compression
  • cord could be around neck or between shoulders
68
Q

variable decelerations: venous compression

A
  • this is the first thing to compress
  • decrease in venous return –> relative hypoxemia –> reflexive increase in FHR
69
Q

variable decelerations: arterial compression

A
  • increase in systemic vascular resistance –> increase in BP and baroreceptor stimulation –> vagal response –> decrease in FHR
70
Q

early decelerations

A
  • GRADUAL symmetric decrease in FHR
  • ONSET BEGINS WITH ONSET OF CONTRACTIONS
  • nadir occurs with the peak of the contractions
  • recovery is at the end of the contraction
  • onset to nadir: >/= 30 sec
  • WITH CONTRACTIONS ONLY
  • benign
  • its okay to be early for dinner but dont be late: late decelerations indicate uteroplacental insufficiency
71
Q

early deceleration causes

A
  • head compression
    -vagal nerve stimulation
72
Q

late decelerations

A
  • GRADUAL symmetric FHR decrease only with contractions
  • onset to nadir: >/= 30 seconds
  • onset begins after contraction
  • nadir always occurs after the peak of the contraction
  • recovery is after the end of the contraction
  • compensatory response: late decelerations with moderate variability is not associated with significant fetal acidemia
73
Q

cause of late decelerations

A
  • uteroplacental insufficiency
  • concerning when: its associated with absent or minimal variability because it reflects hypoxia and increased risk of significant fetal acidemia
74
Q

why are lates late?

A
  1. decrease in 02 sensed by chemoreceptors
  2. causes vasomotor center to have peripheral vasoconstriction (gut, kidneys, limbs) and central redistribution- shunting to (brain heart and adrenals)
  3. these cause increase in BP, baroceptosr stimulation, parasympathetic response = deceleration
75
Q

prolonged decelerations

A
  • gradual or abrupt FHR decrease of >/= 15 bpm in >/= 2 min < 10 min
  • not concerning if: not recurrent, normal FHR baseline before and after deceleration, moderate variability
76
Q

prolonged decelerations

A
  • gradual or abrupt FHR decrease of >/= 15 bpm in >/= 2 min < 10 min
  • not concerning if: not recurrent, normal FHR baseline before and after deceleration, moderate variabilitycc
77
Q

causes of prolonged decelerations

A
  • anything that causes profound change in fetal o2
    1. uteroplacental: tachysystole, maternal hypotension, abruption
    2. umbilical blood flow interruption: cord compression, cord prolapse
    3. vagal stimulation: profound head compression, rapid fetal descent
78
Q

VEAL CHOP

A
  1. Variable deceleration caused by Cord compression
  2. Early deceleration caused by Head compression
  3. Acceleration Is A Okay
  4. Late deceleration is caused by Placental perfusion issue
79
Q

intrauterine resuscitation

A
  1. Position change
  2. IV fluid bolus
  3. CALL FOR HELP
  4. Notify provider and request immediate evaluation
  5. Assess for tachysystole
    -Turn off Pitocin if running
    -have Consider Terbutaline 0.25 mg SQ or IV
  6. Check blood pressure
    -Correct if hypotensive– fluid bolus and meds (Ephedrine 5-10 mg IV or Phenylephrine 0.1 to 0.5 mg IV)
  7. Cervical exam
    -Check for prolapsed cord, rapid cervical dilation, rapid descent
  8. Prepare for possible amnioinfusion
  9. Alter pushing efforts– stop, push every other contraction
80
Q

category one: green

A
  • normal oxygenation
  • includes ALL of these:
    1. normal baseline rate: 110-160
    2. moderate variability
    3. no late or variable decelerations
    4. maybe early decelerations
    5. maybe accelerations
81
Q

goal for category one

A
  • maximize perfusion
  • maintain appropriate uterine activity
82
Q

actions for category one

A
  • intermittent auscultation / uterine palpation if low risk and appropriate
  • intermittente EFM
83
Q

category two: yellow

A
  • all other patterns NOT included in category one or three
  • goal is to prevent worsening and improve oxygenation
  • actions: increase frequency of FHR assessment, continue or initiate EFM, initiate intrauterine resuscitation
84
Q

category three: red

A
  • abnormal oxygenation
  • include EITHER: absent variability with any of these:
    1. recurrent lates
    2. recurrent variables
    3. bradycardia

OR

sinusoidal pattern

85
Q

category three goal

A
  • correct abnormal oxygenation
86
Q

category three actions

A
  • continuous EFM
  • initiate intrauterine resuscitation
  • prepare for c section if no improvement
87
Q

test of fetal well being

A

-Done during antepartum period
-Commonly done for high-risk conditions-DM, pre-eclampsia, IUGR, multiple gestation, postdates, decreased fetal movement
- Non stress test
- biophysical profile
- amniotic fluid volume assessment
- modified BPP
- contraction stress test
- doppler flow studies
- fetal growth and estimation of fetal weight

88
Q

non stress test

A

-FHR will accelerate in response to movement
-Most widely accepted method of evaluation of well-being
-Electronic monitoring is used for 20-40 minutes
- reactive NST: at least 2 FHR accelerations in 20 minute period that meets requirements
- if it meets criteria = low risk for asphyxia in next 2-3 days
- in pregnancies > 32 weeks : >/= 15 bpm above baseline lasting >/= 15 seconds
- in pregnancies 28-32 weeks: >/= 10 bpm above baseline lasting >/= 10 seconds

89
Q

non reactive NST

A

insuffieient accelerations in 40 minutes or increase in FHR didnt meet the criteria
- needs follow up

90
Q
  • reactive NST:
A
  • at least 2 FHR accelerations in 20 minute period that meets requirements
  • if it meets criteria = low risk for asphyxia in next 2-3 days
  • in pregnancies > 32 weeks : >/= 15 bpm above baseline lasting >/= 15 seconds
  • in pregnancies 28-32 weeks: >/= 10 bpm above baseline lasting >/= 10 secon
91
Q

non stress test and fetus sleep cycle

A

-Fetuses have sleep cycles
-If NST is non-reactive in 20 minutes continue testing for additional 20 minutes
-To wake fetus may use sound or vibration to stimulate movement: Vibroacoustic stimulation- “buzzer” that is pushed for no more than 2-3 seconds

92
Q

Biophysical Profile (BPP)

A

-Assessment of fetal reflex activities controlled by the CNS and sensitive to fetal hypoxia
-Score of 2 (present) or 0 (absent) given for the following:
1. NST (reactive = 2 and non reactive = 0) and:
2. Ultrasound of 30 minutes duration
-Fetal breathing movements: at least one episode of fetal breathing lasting at least 30 seconds
-Fetal movement: 3 or more discrete body or limb movements of extremities
-Fetal tone: 1 or more extension/flexion movements of extremities
-Amniotic fluid volume: at least 1 pocket of at least 2 cm or AFI > 5 cm

93
Q

BPP total score of 8-10/10

A

normally oxygenated fetus and low risk of apshyxia
continue care and testing

94
Q

BPP total score of 6/10

A

possible asphyzia
- repeat in 24 hours or possible induction

95
Q

BPP total score of 0-4/10

A

very worrisome
deliver baby

96
Q

Amniotic Fluid Volume Assessment

A

-Measurement of the volume of amniotic fluid with ultrasound
-Amount varies through pregnancy- average 8 to 24 cm

97
Q

Amniotic Fluid Index (AFI)

A

Deepest pockets measured in 4 quadrants of maternal
abdomen via U/S
- sum = AFI

98
Q

Maximum Vertical Pocket (MVP)

A

Largest single pocket of amniotic fluid not persistently
containing fetal extremities or umbilical cord

99
Q

Oligohydramnios

A
  • Complication associated with increased risk of mortality since the amniotic fluid cushions the cord
  • Prolonged fetal hypoxemia causes shunting of blood away from the kidneys which Decreases production of fetal urine and therefore the amniotic fluid volume is decreased
  • AFI of 5 or less or MVP less than 2 cm
100
Q

Hydramnios- also knows as polyhydramnios

A

AFI of > 24 cm or MVP of >/= 8 cm
- may be associated with fetal malformation- obstruction of GI tract, neural tube defect, or fetal hydrops
- higher risk for cord prolapse when membranes rupture

101
Q

Modified Biophysical Profile

A

-Less labor intensive and less expensive than BPP
-Components:
1. NST: Indicator of short-term fetal well-being
2. Amniotic fluid volume assessment–AFI/MVP: Indicator of long-term placental function

results:
reactive NST ans low amniotic fluid = low risk for hypoxia for the next week

102
Q

Contraction Stress Test

A

-Evaluates response of fetus to the stress of contractions (AND HOW WELL HANDLE PERIOD OF LOW 02)
-Contractions causes decreased oxygen transport to fetus
-Adequate testing
-Three contractions in 10 minutes lasting 40 seconds
-Contractions can be spontaneous, induced with Pitocin or nipple stimulation

103
Q

Negative CST

A
  • good
  • no signifigant variable or late decelerations noted
  • associated with good fetal outcomes
104
Q

positive CST

A
  • bad
  • late deceleration noted with at least 50% of contractions
  • require further testing
105
Q

Equivocal CST/Suspicious

A
  • intermittent lates or variable decelerations
  • further testing neede
106
Q

Doppler Flow Studies

A

-Ultrasound evaluation assessing placental function
-Measures blood flow through umbilical artery
-Most common is systolic to diastolic ratio (S/D ratio)-absent, reversed or elevated demonstrates abnormal blood flow
-Commonly used for fetal growth restriction evaluation

107
Q

Estimation of fetal weight in 3rd trimester

A
  1. Methods of evaluation are imprecise
  2. Inadequate or excessive growth may indicate alterations in fetal well-being
  3. Intrauterine growth restriction (IUGR)
    -Any baby below 10th percentile
    -Causes: infections, placental problems, genetic abnormalities, uteroplacental insufficiency
  4. Macrosomia- excessive growth
    0-Weight: 4000-4500 grams
    -cause: diabetes especially poorly controlled because the baby receives the excess glucose from the mom but insulin wont pass the placenta so gain weight
108
Q

Evaluation of Fetal Lung Maturity

A

-Used prior to elective childbirth of fetus before term (39 WEEKS)
-If lungs immature- delay delivery
-If lungs mature risk of Respiratory Distress Syndrome is low
-Amniotic fluid obtained by amniocentesis
1. Lecithin/Sphingomyelin Ratio
-Two components of surfactant
-When the L/S ratio is > 2:1 demonstrates low risk of RDS and mature lungs
2. Phospatidylglycerol (PG)
-Another component of surfactant
-Appears at about 36 weeks gestation and continues to increase until term
-Presence demonstrates low risk of RDS

  • NOT USED WITH SPONTANEOUS LABOR

OB (12 decks)

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