Fetal assessment

Question 1

made its debut for clinical use in the early 1970s the anticipation was that its use would result in less long-term neurologic impairment in the form of cerebral palsy however research has not been able to show that intrapartum fetal heart rate monitoring leads to a significant decrease in neonatal neurological morbidity still electronic fetal monitoring is a useful tool for visualizing fetal heart rate and uterine contraction patterns on a monitor screen

Answer 1

When electronic fetal heart rate monitoring

Question 2

Because labor is a period of physiologic stress for the fetus frequent monitoring of fetal status is part of the nursing care
Fetal Response
Uterine Activity
Fetal Compromise

Answer 2

Basis for monitoring

Question 3

during labor the fetal oxygen supply can decrease in a number of ways during labor
Reduction of blood flow through maternal vessels
Reduction of oxygen content in maternal blood
Alterations in fetal circulation
Reduction in blood flow to the placenta

Answer 3

Fetal Response

Question 4

reduction of blood flow through the maternal vessels as a result of maternal hypertension hypotension or hypovolemia

Answer 4

Reduction of blood flow through maternal vessels

Question 5

reduction of the oxygen content in the maternal blood as a result of hemorrhage or severe anemia

Answer 5

Reduction of oxygen content in maternal blood

Question 6

alterations in fetal circulation occurring with compression of the umbilical cord or partial placental separation or complete abruption or head compression

Answer 6

Alterations in fetal circulation

Question 7

or reduction in blood flow to the intervala space in a placenta secondary to uterine hypotonus in other words the uterus is Contracting too much or secondary to deterioration of the placental vasculature associated with maternal disorder such as hypertension or diabetes mellitus little while being during labor can be assessed by the response of the fetal heart rate to these contractions uterine activity can also be identified as normal or abnormal

Answer 7

Reduction in blood flow to the placenta

Question 8

normal uterine activity is far as the frequency duration and strength and resting tone Etc what’s important to know from this table is that you know contractions that are occurring too often that are not allowing the fetus to have a break is going to cause problems later on that’s that’s hypertonicity that’s called too many contractions is called tacky systole too strong a contraction is called hypertonicity

Answer 8

Uterine Activity

Question 9

right now the goals of an intrapartum fetal heart rate monitoring are to identify and differentiate the normal or reassuring patterns from the abnormal or non reassuring patterns which can indicate fetal compromise abnormal fetal heart rate patterns are those associated with fetal hypoxemia it’s uncorrected hypoxemia can deteriorate to severe fetal hypoxia - inadequate supply of oxygen at the cellular level that can cause metabolic acidosis can lead to academia or increased hydrogen ion content in the blood

Answer 9

Fetal Compromise

Question 10

Intermittent auscultation
Electronic Fetal Monitoring

Answer 10

Monitoring techniques

Question 11

involves listening to the feet of heart sounds at periodic intervals to assess you to heart rate it’s not continuous it’s easy to use it’s inexpensive and it’s less invasive it doesn’t tie a woman down to the bed or make them more uncomfortable enter mittenden oscultation is intermittent significant events because it’s intermittent significant events may occur during a time when the fetal heart rate is not being auscultated and addition does not provide a permanent documented visual record of the fetal heart rate and cannot be used to assess visual patterns so this is not something that we typically would use somebody in active labor electronic fetal monitoring
just telling us what the heart rate is it doesn’t tell us anything about the contractions
Doppler/Fetoscope
Palpation

Answer 11

Intermittent auscultation

Question 12

how we do this in the office is by Doppler so when we are coming out a little minutes coming in to be assessed for her routine prenatal care we listen to the baby via Doppler some of these more old school techniques are fetuscopes

Answer 12

Doppler/Fetoscope

Question 13

how we assess the contractions is by feel by palpation The Examiner should keep his or her fingertips cuz that’s what feels more of the sensation placed over the fundus before during and after contraction the contraction intensity is usually described as mild moderate or strong the contraction duration is measured in seconds from the beginning to the end but the frequency that’s how we teach women to to determine how far apart they’re contractions are is measured from the beginning of one contraction to the beginning of the next we went over that in class resting tone is what’s happening when the uterus is not Contracting you feel the contraction come on you feel that it’s Peak and then you feel it subside once a contractions completely gone what is the resting tone it should be soft

Answer 13

Palpation

Question 14

to assess the adequacy of fetal oxygenation during labor
can feel the top of their head with a cervical or vaginal exam but I can’t see what’s going on with the baby this is how we interpret is by assessing adequacy of fetal oxygenation the two modes are external and internal
External
Internal Monitoring

Answer 14

Electronic Fetal Monitoring

Question 15

Ultrasound transducer
Tocotransducer

Answer 15

External

Question 16

Confine woman to bed/chair
Separate transducers are used to monitor the fetal heart rate and contractions the ultrasound transducer works by reflecting high frequency sound waves off of moving interface in this case the fetal heart rate and the fetal heart and the valves

Answer 16

Ultrasound transducer

Question 17

measures UA trans abdominally so you’re going to measure the uterine activity through the abdomen it’s placed over the fundus which is the optimal pressure sensitive surface to to feel the when a contraction comes and when it subsides it can measure and record the frequency and approximately how long the contraction is but it is absolutely no indication of how strong the contraction is you’re having to ask Mom or put your hands on her

Answer 17

Tocotransducer

Question 18

the UA in the lower section this is how we do this so if the baby is vertex you’re going to find the heart rate below the umbilicus if the baby is breach you’re going to find the heart rate above the umbilicus
internal we use you can kind of see catheter up against the baby that’s the entry heater and pressure catheter it’s hooked to the monitor it’ll tell us exactly how strong contractions are in millimeters of mercury and then this little tiny black electrode that’s attached to baby’s head it’s a very fine metal stainless steel coil that just goes up and that tells us exactly what the heart rate is so they’re not having to chase the baby down
these are two invasive procedures as far as a monitoring the baby so this is not the first thing done
if you’re having a hard time measuring contractions or having a hard time keeping up with a baby’s heart rate very imp things to assess - do internally
internal monitor the technique of continuous internal fetal heart rate or uterine activity monitoring provides a more accurate appraisal of fetal well-being during labor then it external monitoring because it’s not interrupted by movement or by Mom’s size for this type of monitoring the membranes must be ruptured and the cervix must be sufficiently dilated to actually put the monitors inside the presenting part must be low to allow placement
Spiral electrode
Intrauterine pressure catheter

Answer 18

Internal Monitoring

Question 19

internal monitoring of the fetal heart rate is accomplished by attaching a small spiral Electro

Answer 19

Spiral electrode

Question 20

The intrinsic rhythmicity of the fetal heart the central nervous system and the fetal autonomic nervous system control the fetal heart rate an increase in sympathetic response results in acceleration whereas an increase in parasympathetic response to the slowing the parasympathetic
Baseline fetal heart rate is the average rate during a 10 minute segment of tracing periodic changes: periods of March variability you’re not counting that Baseline and segments of the Baseline that differ by more than 25 beats per minute like
so you look at a 10 minute tracing you get the average rate the normal range should be 110 to 160 but the actual fetal heart rate that we get is a one number
Normal Range is 110-160 bpm
Variability
Tachycardia
Bradycardia

Answer 20

Baseline FHR

Question 21

described as irregular waves or fluctuations in the Baseline due to heart rate of two cycles per minute or greater variability s
absent is the scariest it’s the most ominous of the variability descriptors so but minimal is very very close to absence
Absent
Minimal
Moderate
Marked
Sinusoidal

Answer 21

Variability

Question 22

amplitude range of that fetal heart rate fluctuation that is not detectable to the unaided eye looks like somebody got a pencil and quite literally drew a line across the tracing minimal variability has an amplitude ranges detectable but is less than five beats per minute

Answer 22

Absent

Question 23

classified as either abnormal or indeterminate so not of warm fuzzy feeling definitely not for absent it can result from fetal hypoxemia and metabolic acidymia sleep cycle anomalies and preexisting neurologic injury

Answer 23

Minimal

Question 24

considered normal and it’s presents reliably predicts a normal fetal acid base balance so this is a kiddo it’s not affected significantly by fetal sleep cyclesia and neurologic injury
this baby is well oxygenated, no tachycardia, and neurologically intact that’s what

Answer 24

Moderate

Question 25

it’s a little bit more unclear in many cases it’s likely represents a normal variant but this is a fluctuation of greater than 25 beats per minute
Where to compare that to an EKG tracing that would look like what maybe v-fib
this is more of an ominous sign others have been

Answer 25

Marked

Question 26

looks like a more like a smooth undulating wave and you’ll see that a lot of times after you give Mom an opioid for pain relief and uncommon pattern if it’s not because of an opioid it’s because baby is anemic there’s something else going on but it’s not a typical pattern that you’ll see

Answer 26

Sinusoidal

Question 27

> 160
of itself is not so bad however it can be an early sign of fetal hypoxemia especially if we’re seeing this tachycardia with late decelerations and minimal are absent variability so that’s just one aspect of the feet of heart rate we’re looking at it can be caused by maternal or fetal infection from mom is premature prolonged rupture of the membrane this is somebody’s water has broken and they don’t go into labor maybe they’re premature
can also anything that’s going to elevate Mom’s heart rate so if she is smoking or doing drugs that’s also going to raise babies heart rate is a baseline fetal heart rate
Early sign of fetal hypoxia
Increased maternal temp
PPROM
Drugs

Answer 27

Tachycardia

Question 28

<110
less than 110 for 10 minutes or longer so the 10 minute period that we’re going to talk about if anything occurs greater than 10 minutes it’s called a baseline change so it has to be less than 110 and it has to occur for longer than 10 minutes it’s often caused by some type of fetal cardiac problems such as a structural defect involving pacemakers or the conduction system it can be a viral cause low blood sugar for Mom and maternal hypothermia but typically medications do not cause bradycardia
Later sign of fetal hypoxia
Decreased maternal blood pressure
Prolonged umbilical cord compression
Terminal

Answer 28

Bradycardia

Question 29

they usually go up by at least 15 beats and last for 15 seconds
they are most likely associated with fetal movement and sometimes it just occurs spontaneously
highly predictive of normal fetal acid-base balance we like to see these
Visually apparent abrupt increase in FHR above the baseline rate
15 beats x 15 seconds
Associated with fetal movement
Highly predictive of normal fetal acid-base balance

Answer 29

Accelerations - Periodic and episodic changes in FHR

Question 30

these are visually apparent gradual decreases in and a return to the Baseline associated with the contractions most often it is caused by fetal head compression almost like a little bit of a vagal reaction because of the pressure of the contraction think about what this contraction is doing there is a little bit of a pause and circulation at the peak
there’s no known relationship to fetal oxygenation
it is head compression and it starts represent a fetal autonomic response to changes in the intracranial pressure and or cerebral blood flow caused by that compression you don’t have to do anything about this you don’t intervene with accelerations you’re not going to really do any interventions here the one that you may do especially if they’ve been in labor for a time or maybe they’re a new admission and you’re not sure how far dilated they are is you know a cervical exam a vaginal exam
Visually apparent, gradual decrease in and return to baseline FHR
Associated with uterine contractions
Caused by transient fetal head compression
No known relationship with fetal oxygenation

Answer 30

Early decelerations - Periodic and episodic changes in FHR: decelerations

Question 31

these are visually apparent gradual decrease
it sounds just like an early except the difference in this is that it begins after the contraction has started and the lowest point of the deceleration occurs after the peak of the contraction so it’s visually late occurring
a little bit of a late onset and a late recovery it typically will actually end the deceleration in well after the contraction has ended
late decelerations are caused by a reflex fetal response to transient hypoxemia during a uterine contraction that reduces the delivery of oxygenated blood to the interbiliary space of a placenta a number of conditions can cause this disruption of oxygen transfer: maternal hypertension or uterine hypertonus (too many contractions), utero placental insufficiency (disruption of oxygen transfer is utero), placental insufficiency (not perfusing this baby well)
if Interruption of fetal oxygenation results in metabolic acidemia late details may result from direct hypoxic myocardial depression during a contraction these require intervention
Visually apparent, gradual decrease in and return to baseline FHR
Begins after the contraction has started and lowest point is after the peak of the contraction
Associated with uterine contractions
Caused by reflex fetal response to transient hypoxemia

Answer 31

Late decelerations - Periodic and episodic changes in FHR: decelerations

Question 32

fetal heart rate is to find as a visually abrupt and apparent decrease in a fetal heart rate below the Baseline the decrease is at least 15 beats and last for 15 seconds
acceleration is caused by compression of the vessels
have a U V or W shape
Difference occasional variables have very little clinical significance
seeing one every now and then not a big deal
If it’s occurring with every single contraction and in between contractions these are repetitive variable decelerations it could be because the cord is stretching babies got a hand on umbilical cord but either way there is some umbilical cord compression that is causing this
Visually abrupt and apparent decrease in FHR below the baseline
The decrease is at least 15 bpm x 15 seconds and rreturns to baseline in less than 2 minutes
Cord compression
Shaped like U, V, or W

Answer 32

Variable decelerations - Periodic and episodic changes in FHR: decelerations

Question 33

visually apparent decrease in the fetal heart rate of at least 15 beats a minute below the Baseline and last for longer than 2 minutes but less than 10 cuz what happens after 10 minutes that’s a baseline change
prolonged accelerations are caused when the mechanisms responsible for late or variable deceleration
can cause an interruption in the fetal Action Supply long enough to produce these can occur anywhere along the auction pathway: at the level of the maternal lungs resulting from maternal apnea if Mom is not going to breathe she’s the cause of the prolong deceleration at the level of the umbilical cord/if this cord prolapses - cord comes out in a stretched and there’s prolonged cord compression that will also cause a prolonged deceleration in the heart rate either way this has to get corrected
if we cannot correct this then we have to go back to do a C-section because the baby will not tolerate this for a prolonged amount of time
Visually apparent decrease of at least 15 bpm below baseline and lasting > 2minutes but less than 10 minutes
Caused when mechanisms for late or variable decelerations last for an extended period

Answer 33

Prolonged decelerations - Periodic and episodic changes in FHR: decelerations

Question 34

fetal heart rate and uterine activity tracings are evaluated regularly throughout labor
in fact the guidelines suggests that fetal heart rate tracing be evaluated at least every 30 minutes during the first stage of Labor and every 15 minutes during the second stage of Labor in a low risk women so then we have to Define what’s low risk versus high risk and sometimes it’s based on you know A1A Cog and sometimes it is your institutional policy
clients are on Pitocin so then you’re having to assess even more often and if for that for that matter depending on what’s making them high risk the fetal heart rate tracing will be evaluated about every 15 minutes in the first stage and every five there is a lot of charting that has to be done we are constantly evaluating interpreting these strips
interventions that we do are based on the clinical Judgment of a complex integrated process there again that’s why the Acuity of these patients are very different
Categorizing FHR tracings
Nursing management

Answer 34

Pattern recognition and interpretation

Question 35

Normal and strongly predictive of normal fetal acid-base status at the time of observation
strongly predictive of normal fetal acid-base status at the time of the observation when we always say at this time because that is that can change in an instant at the time it is a category one we’re relatively happy to monitor

Answer 35

Category I - Categorizing FHR tracings

Question 36

Indeterminate
Continue Observation/Evaluation
kind of the catch all I’m not super thrilled about it I’m not 100% sure the baby is okay but I’m sure that we don’t need to go ahead and get the baby out right this minute so it’s indeterminate we’re going to continue to observe evaluate maybe do some interventions and reevaluate to see if we can’t make it become a category one

Answer 36

Category II - Categorizing FHR tracings

Question 37

Abnormal
Immediate interventions are required
tracings are abnormals category one is normal Category 3 is absolutely abnormal and Category 2 is indeterminate I can’t tell yet Category 3 tracings require immediate evaluation and prompt intervention

Answer 37

Category III - Categorizing FHR tracings

Question 38

Purpose: Improve fetal oxygenation
Box 15.8 (6th edition) “Management of Abnormal Fetal Heart Rate Patterns”

Answer 38

Nursing management

Question 39

what are we trying to do improve fetal oxygenation that is our purpose the five essential components of fetal heart rate tracings that must be evaluated regularly are Baseline rate Baseline variability accelerations deceleration and changes are Trends over time whenever one of these five essential components is assessed as abnormal corrective measures must be taking to do what improve fetal oxygenation

Answer 39

Purpose: Improve fetal oxygenation

Question 40

Administer O2
Side-lying position
IV fluid bolus
Interventions for specific problems

Answer 40

Box 15.8 (6th edition) “Management of Abnormal Fetal Heart Rate Patterns”

Question 41

for you how do you as a nurse manage abnormal so when you determine that okay we have a category 2 tracing maybe we’re having some variable decelerations maybe the heart rate Baseline has changed what do you do about it remember what I said what is it why is it happening and what do I do about it when you’re thinking about fetal heart rate management that’s what you need to think about so at the bare minimum every bed has got O2 at it and so because we’re because we’re trying to improve fetal oxygenation how do we do that we have to bump up Mama’s oxygenation so when we improve mommy’s oxygenation We There by improve the fetal oxygen so administer auction by non-rebreather mask at a rate of 10 L per minute for at least 15 to 30 minutes this is not put the oxygen mask on Mom and leave it for 8 hours you put it on the 15 to 30 minutes and see if it improves the heart rate if that doesn’t improve it then you’re going to go on into a sister to the sideline position

Answer 41

Administer O2

Question 42

remember the big heavy uterus laying on that on those major vessels we need to make sure that Mom is off that uterus is off of those major vessels to improve oxygenation and then if that’s not do it now we’re going to give her an IV fluid bolus

Answer 42

Side-lying position

Question 43

maternal blood thought you increase that blood volume by increasing the rate of primary IV infusion to increase that profusion of oxygenation to the fetus does that all make sense to you now these are your three least invasive things to be doing to Mom and you may see that they are all done in conjunction we may not just put option on her we may go ahead and do that and put her in the sideline position or do all three to see if we can’t fix it but that’s usually the order takes a little bit more work especially if she has an epidural in place and the IV fluid bullets

Answer 43

IV fluid bolus

Question 44

Pitocin going not in a routine labor she won’t so if she has low blood pressure caused by an epidural increase her rate of the primary IV infusion change to the lateral position maybe even have to keep the CRNA or in a seizure provider nearby to give her some ephedrine to boost up that blood pressure cause and effect what’s the cause hypertension - fix the baby’s oxygenation
if she’s having too many contractions if she’s having too many contractions and she’s on Pitocin yeah shut down the Pitocin or follow your orders cut it in half cut it back a little bit always follow your your doctor’s orders
if there is a abnormal fetal heart rate pattern during the second stage of Labor what second stage it’s pushing then we have to change Mama’s pushing from closed gottise to open glottis pushing maybe just push every other contraction
you have to modify that based on what’s going on

Answer 44

Interventions for specific problems

Question 45

Assessment techniques
Interventions

Answer 45

Other methods of assessment and intervention

Question 46

Scalp stimulation
Vibroacoustic stimulation
Umbilical Cord Acid-Base

Answer 46

Assessment techniques

Question 47

you’re looking you’re assessing baby on the Monitor and not seeing any accelerations it’s been 15 20 30 minutes it could be the baby is Comfortably asleep inside tucked up inside that uterus or maybe there’s something else going on but we can actually help stimulate an acceleration by doing one of two things so the first thing that we can do is actually stimulate the scalp and usually can see here from the picture just doing a vaginal exam and taking her index finger and just rubbing across the the skull of the baby will kind of wake up stimulation and then you’re going to see a representative increase in the heart rate as you can see from the tracing that coincides with that that scalp simulation

Answer 47

Scalp stimulation

Question 48

we can stimulate baby to get an acceleration is vibro acoustic simulation and you’ll see those at the bedside and labor and delivery and kind of like an alarm clock it’s a buzzer you you put up onto Mama’s abdomen and you hit this button and it creates a really strong vibration it sounds like a baby on the inside will sound like an alarm clock going off they will typically elicit a response to that that looks like an acceleration and if that happens then we’re good to go could be that you caught the baby in a sleep cycle in umbilical acid base determination so depending on how the baby has looked on the fetal heart rate

Answer 48

Vibroacoustic stimulation

Question 49

delivering provider may ask a nurse for cord gases or the umbilical cord acid base determination so Court gas is just like blood gases only were withdrawing these from the vein and artery so one artery in the vein of the umbilical cord
that’s one way that we can determine babies well-being - APGAR score
If we’re just kind of unsure what we’ll get these samples and then compare it to see how how the baby

Answer 49

Umbilical Cord Acid-Base

Question 50

Amnioinfusion
Tocolytic Therapy

Answer 50

Interventions

Question 51

why do babies have variable decelerations cord compression so if the cord could if the variables are getting to the point where we’re having repetitive variable decelerations and mama’s water is broken one intervention we can do is
that has to be done with an intrauterine pressure catheter as you can see from
providers like it just hung to gravity the important thing about amnioinfusion is that it will help buffer that cord float that cord
many times if the cord compression is severe enough and you introduce an amnio infusion into the uterus and it floats the cord well enough you will resolve your variable decelerations but you have to be careful that you’re not putting too much fluid into Mama’s abdomen or into her uterus cuz that’ll aggravate the uterus will end up having an increase in the resting tone and the labor pattern make it a bit dysfunctional so we may hinder progress by doing this
we have to make sure that we see some output to the vagina on our Chucks or pad underneath mom we don’t want to over distance that

Answer 51

Amnioinfusion

Question 52

the relaxation of the uterus and this can be achieved through drugs and these can be administered with moms having excessive uterine contractions spontaneously
if we turned off the pitocin and her contractions are still every minute then we can administer some drugs: it’s some other conditions that may warrant that
if we’re getting her prepared for a C-section or trying to slow things down a little bit we can get her some breathing at that point

Answer 52

Tocolytic Therapy