fetal assessment during labor Flashcards
Leopold’s Maneuvers to diagnose
Fetal position & presentation
Number of fetuses
Degree of presenting part’s descent/engagement into the maternal pelvis
Expected location of best spot (PMI) to hear the FHR
Leopold’s Maneuvers nursing considerations
- Make sure mother is not flat on her back
- Have mother void before procedure
- Assess for contractions & if contracting wait until contraction is over
one strip is how many min
8 min
1 collum =
1 min
1 box
10 beats/10 seconds
normal range of heart rate
110-160
baseline
wear heart rate settles for least 2 min
acceleration
at least 12 beats above baseline last least 15 seconds
- at least 10 beats above baseline at last 10 seconds for a 32 weeker
VEAL
variable decelerations
early decelerations
accelerations
late decelerations
CHOP
cord compression
head compression
okay
placental insufficiency
variable decelerations
cord compression
early decelerations
head compression
- prepare for labor
accelerations
okay
late decelerations
placental insufficiency
cause: utero-placental insufficiency
clinical significant: Abnormal pattern; associated w/ fetal hypoxemia, low APGAR scores, fetal academia, an ominous sign esp. if associated w/ fetal tachycardia & loss of variability
prolonged decelerations
decrease in FHR at least 15 beats below baseline lasting at least 2 minutes but not longer than 10 minutes
interventions for declerations
LION
- Turn patient to left or right lateral position
- If pt on labor inducing medication (cervical ripening agent or oxytocin IV); remove it
- Administer a bolus of current IV fluids of 500-1000ml
- Administer O2 100% via non-rebreather (until fetus recovers)
- Notify provider [anticipate orders for internal monitors, tocolytic medications, or possible amnioinfusion (for deep recurrent variable decels)
- Perform sterile vaginal exam
- If No improvement, prepare for c-section
category 1
- Baseline 110-160 bpm
- Moderate baseline FHR variability
- Late or variable decelerations are absent
- Early decelerations and accelerations may be present or absent
- NORMAL – followed in routine manner, no specific action required
category 2
- Include ALL FHR tracings not categorized as I or III
- Bradycardia/Tachycardia
- Minimal or marked variability
- Are indeterminate – require evaluation and continued surveillance and reevaluation
category 3
- Absent variability AND any of the following:
- Recurrent late decelerations, recurrent variables, bradycardia
- Sinusoidal pattern
- ABNORMAL – require PROMPT evaluation/delivery
