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I&M II > III. Maternal & Fetal Monitoring > Flashcards

III. Maternal & Fetal Monitoring Flashcards

1
Q

How many stages of labor?

A

3

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2
Q

What stage is the longest stage?

A

Stage one

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3
Q

Begins with uterine contractions and continues until cervix fully dilated to 10cm.

A

Stage 1

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4
Q

Begins with cervical dilated to 10 cm until delivery of Fetus

A

Stage 2

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5
Q

stage: Until delivery of placenta

A

stage 3

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6
Q

The ideal labor epidural should cover sensory loss from ____ to ____.

A

T10 to S5

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7
Q

First Stage of labor:

Afferent/Efferent nerve impulses from the lower uterine segment and cervix cause visceral pain

A

Afferent

Afferent = sensory
Efferent = motor

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8
Q

First Stage of Labor:

Nerve cell bodies are located in the dorsal root ganglia of ____ to ____.

A

T10 to L1

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9
Q

What dermatome level is T10

A

umbilicus

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10
Q

what stage has pain that is poorly localized?

A

Stage 1

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11
Q

what stage of labor includes somatic pain that is well localized?

A

Stage 2

Afferent nerves innervating the vagina and perineum causes somatic pain which is better localized.

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12
Q

Stage 2 Labor:

somatic pain impulses (from the vagina and perineum) travel primarily via the ____ to dorsal root ganglia of S1-S5

A

pudendal nerve

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13
Q

How to assess a sensory nerve block:

A
  1. Explain the procedure and purpose to the patient
  2. Choose tool (ice cube, cold alcohol 4x4, broken tongue depressor)
  3. Establish Control (Ice): place the ice on an area well away from the possible dermatome cover such as the neck or face and ask if they feel cold.
  4. Apply the ice to an area likely blocked on the same side of the body and ask the patient, does this feel the same cold or different?
  5. Apply ice to areas above and below this point until it is clear at which level the top and bottom of the block is covered.
  6. Repeat the procedure on the opposite side of the body, as blocks may be uneven or unilateral.
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14
Q

Dermatome level:

C4

A

Clavicles (C is 4 clavicles)

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15
Q

Dermatome Level:

T4

A

Nipples (T is 4 tips of the nips)

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16
Q

Dermatome Level:

T6

A

Xiphoid

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17
Q

Dermatome Level:

T10

A

Umbilicus (0 looks like belly button)

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18
Q

Dermatome Level:

S1

A

Pinky Toe

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19
Q

Dermatome Level:

L1

A

Inguinal Line (top of bathing suit tan line - L1 is Lifeguard 1)

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20
Q

name of syndrome that affects pregnant women when laying supine = ↓ venous return and CO.

A

Aortocaval Compression Syndrome

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21
Q

When does aortocaval compression syndrome begin during pregnancy?

A

16-20 weeks gestation

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22
Q

Signs and symptoms of Aortocaval Compression Syndrome?

A
  • HoTN
  • Pallor
  • Sweating
  • Nausea & Vomiting (2/2 to HoTN)
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23
Q

Treatment for Aortocaval Compression Syndrome?

A

Left Uterine Displacement (LUD)

  • wedge under right hip
  • 15º tilt
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24
Q

LIst HTN disorders experienced during pregnancy:

A
  1. Gestational HTN/Pregnancy Induced HTN (PIH)
  2. Pre-Eclampsia
  3. Eclampsia
  4. Sever Pre-Eclampsia
  5. HELLP Syndrome
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25
Q

What is considered Gestational HTN/PIH?

A

139/89 after 20 weeks

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26
Q

Etiology of Gestational HTN/PIH

A

1. Abnormal sensitivity to catecholamines & hormones
2. Fetal maternal antigen antibody reaction’s
3. Production of vasoactive prostaglandins (Thromboxane A & Prostacycline)

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27
Q

What is a major symptom of preeclampsia that is missing in Gestational HTN/PIH?

A

proteinurea

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28
Q

Gestational HTN/PIH usually resolves by ____ postpartum and treatment is NOT needed.

A

12 weeks

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29
Q

Preeclampsia:

BP: ____
Proteinurea: ____
Sx: ____

A

> 140/90
300mg/24 hr
Edema, Headaches, Visual disturbances, Hyperreflexia

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30
Q

Severe Preeclampsia:

BP: ____
Proteinurea: ____
Sx: ____

A

160/110
>5g/24 hr
HELLP Syndrome (8Hemolysis, Thrombocytopenia, ↑Liver Enzymes, ↓PLT count)

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31
Q

The presence of what hallmark symptom graduates preeclampsia to eclampsia?

A

Seizures

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32
Q

Because these HTN pregnancy disorders can affect ____, we should monitor closely and give careful consideration to regional anesthetics.

A

blood coagulation

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33
Q

What coag studies are we interested in for pregnant HTN patients?

A

Full coag studies:
- PT
- PTT
- Fibrinogen

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34
Q

Most providers require what range of platelets IOT consider regional anesthesia?

A

70-100k

consider trend in PLT count

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35
Q

Is it safe to remove epidural catheter if PLT low?

A

Catheter should be left in

Get another set of labs and wait until PLT is safe range (100+ ideally), maybe for couple days

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36
Q

HELLP syndrome is a life threatening condition and is considered a sub-variant of ____.

A

Severe Pre-Eclampsia

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37
Q

HELLP stands for:

A

H: Hemolysis (RBC breakdown = Hgb breakdown = ↑Bilirubin)

EL: Elevated liver enzymes (ALT, AST)

LP: Low PLT count/thrombocytopenia (<100k)

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38
Q

What major vital may be normal with HELLP syndrome, delaying diagnosis?

A

BP

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39
Q

HELLP Tx:

A
  • Transfusion
  • Bedrest
  • Continuous monitoring of mom & baby
  • Mg
  • manage HTN if present
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40
Q

At what point do we treat HTN in pregnant patients?

A

BP >159/109

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41
Q

What are common drugs used to treat PIH?

A
  • Oral Hydralazine (most common)
  • Labetalol
  • Clonidine
  • Nifedipine
  • NTG/SNP
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41
Q

What are specific treatments for Preeclampsia?

A
  1. Manage HTN (same as PIH)
  2. Seizure Prophylaxis: Mg Sulfate (2 g/15min ≤ 4-6 g loading dose followed by 1-2 g/hr)
  3. Definitive treatment is delivery of baby [BQ] (Board Question)
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42
Q

Specific treatments for Eclampsia

A
  1. Prevent aspiration
  2. Manage airway
  3. Control seizures
    • Midazolam 1-2 mg
    • Ativan 2-4 mg
    • Diazepam 5-10 mg (Textbook answer)
    • THEN Mg Sulfate 1-2 g/hr
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43
Q

Mg Sulfate helps with both seizure prophylaxis and ____.

A

BP management

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44
Q

If mother starts seizing while pregnant, what procedure will take place immediately.

A

STAT c-section

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45
Q

uses for Mg Sulfate:

A
  1. Prevention of Eclampsia & Seizures
  2. Tocolytic (inhibits uterine contraction, slow/stops premature labor)
  3. Cerebral Protectant for premature babies
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46
Q

Therapeutic level of Mg Sulfate

A

4-8 mEq/L (4.8-9.6 mg/dL)

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47
Q

Patients receiving Mg Sulfate should be closely monitored for ____.

A

Mg Toxicity

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48
Q

T/F: Mg Toxicity symptoms are easily discernable in pregnant patients.

A

False

are the first symptoms of magnesium toxicity are fatigue, nausea and vomiting, blurred vision, EKG changes. These symptoms are not uncommon in otherwise healthy pregnant patients

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49
Q

What EKG changes are a result of magnesium toxicity?

A
  1. Prolonged PRI
  2. Widened QRS
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50
Q

Mg Sulfate dose dependent side effects table picture

A
51
Q

Treatment for Mg toxicity?

A

1 g Calcium Gluconate IV over 10 min

52
Q

What consideration should anesthetist make if a patient is on magnesium at therapeutic levels?

A
  1. Mg potentiates NMB : Reduce doses of Rocuronium
  2. Tocolytic ∵ can cause post-partum hemorrhage: Hemabate, Methergine, Pitocin
53
Q

3 types of fetal monitoring

A
  1. Auscultation
  2. Electronic Fetal Monitoring
  3. Internal fetal monitoring
54
Q

2 Auscultation methods:

A
  1. Fetoscope (low-tech)
  2. Portable Doppler
55
Q

Benefits of Auscultation methods:

A
  1. Quick & portable
  2. Detects Baseline
  3. FHR rhythm and dysrhythmias
  4. Helps detect changes in heart rate
  5. Differentiates maternal from fetal HR
56
Q

Limitations of Auscultation methods:

A
  1. No printout: cannot assess changes over time
  2. Not continuous: acute changes can be missed
  3. Cannot assess variability
  4. Maternal position limiting (supine difficult)
  5. Difficult to use on obese patients
57
Q

Electronic Fetal Monitoring (EFM) uses what two external belts?

A
  1. Doppler (FHR monitor)
  2. Tocodynamometer (contraction monitor)
58
Q

The tocodynamometer uses a ____ that records uterine contraction duration & intervals.

A

pressure transducer

59
Q

Electronic fetal monitoring picture

A
60
Q

Electronic fetal monitoring picture 2

A
61
Q

EFM Benefits:

A
  1. Noninvasive
  2. Continuous documentation
  3. Not labor intensive
  4. Shows variability (over time)
  5. Works well independent of pt position
62
Q

EFM Limitations:

A
  1. Restricts patient movement
  2. Not ECG but measures cardiac motion
  3. Double counting or picks up maternal heart tones (especially if mom HR is tachycardic)

newer technology is wireless and does NOT restrict movement

63
Q

Internal Fetal Monitoring uses a ____ ____ electrode.

A

fetal spiral

64
Q

what must occur before the fetal spiral electrode is used for fetal monitoring?

A

The amniotic sac must be broken in order to allow obstetrician to place electrode vaginally through uterus onto baby’s forehead.

65
Q

What method is most accurate assessment of fetal HR?

A

Internal Fetal Monitoring via Fetal Spinal Electrode (FSE)

66
Q

Benefits of FSE:

A
  1. Detects FHR variability
  2. Detects dysrhythmias (R-R interval monitoring on EKG)
  3. Mother may have mobility

new tech has wireless models to allow for ambulation

67
Q

Limitations of FSE:

A
  1. Can be used only after the membranes of the amniotic have ruptured (after “water breaks”): ↑risk of infection (invasive)
  2. Discomfort during placement
  3. Contraindicated in patient’s with herpes outbreak
    ↑risk of transferring virus to baby
  4. Contraindicated in HIV+ women due to infection risk.

likely not an option during early labor

68
Q

2 methods of monitoring uterine activity:

A
  1. Tocodynamometer: external
  2. Intrauterine pressure catheter (IUPC): Internal
69
Q

Main limitation of external tocodynamometer

A

hard to use in obese patients and dependent on position

70
Q

Main benefit of external tocodynamometer:

A

noninvasive

71
Q

Main benefits of IUPC:

A
  1. More accurate uterine pressure (mmHg) monitoring
  2. Accurate timing of heart rate changes with contraction
72
Q

Main limitation of IUPC:

A

Invasive

73
Q

Where is tocodynamometer placed?

A

over the fundus of uterus

superior of the two belts on the abdomen

74
Q

Internal Fetal Monitoring Fetal Spinal Electrode Picture

A
75
Q

How do we determine the baseline of the FHR?

A

the average FHR over 10 min, rounded to the nearest 5 bpm

76
Q

Normal fetal heart rate (FHR)

A

110-160

77
Q

what does fetal heart rate best indicate clinically (i.e., what other vital is it closely correlated with)?

A

how well oxygenated the baby is (oxygenation status)

78
Q

Two classifications of clinical changes in fetal heart rate:

A
  1. Accelerations
  2. Decelerations (Early, Late, Variable)
79
Q

FHR: The Graph Display

the intervals between the vertical red lines represent ____ minute/s.

A

1 minute

80
Q

FHR: The Graph Display

Fetal heart tracing is displayed in the lower/upper pane?

A

upper

81
Q

FHR: The Graph Display

what is displayed in the lower pane of the FHR graph?

A

uterine activity

82
Q

FHR Display Graph Picture

A
83
Q

what is the normal beat-to-beat variability in a healthy fetus?

A

5-25 bpm

measured from peak HR to lowest HR

84
Q

beat to beat variability:

Minimal: _____
Moderate: _____
Marked: _____

A

Minimal: >5
Moderate: 5-25
Marked: >25

85
Q

The following situations can decrease B-B variability:

A
  1. Hypoxia/Acidosis
  2. Congenital anomalies
    ø Anencephalic fetus: born w/o part of brain/skull
  3. Medication Administration (↓CNS + Cross Placenta)
    ø Narcotics
    ø Sedatives/Anesthetics
    ø High dose anticholinergics
86
Q

If signs of fetal distress are present what should be done first?

A

alert obstetrician immediately

87
Q

Determine variability:

A

Normal “Moderate” Variability

88
Q

Determine variability:

A

Minimal

BUT this is sign of distress: there should be some degree of variability coinciding with contractions

89
Q

Fetal Tachycardia range:

A

> 160 bpm

90
Q

causes of fetal tachycardia

A
  1. Recovery following asphyxia
  2. Maternal or fetal infection
  3. Catecholamine administration
  4. Tachydysrhythmias
  5. Thyrotoxicosis
91
Q

Fetal Bradycardia range:

A

<110 for >2 MINUTES

92
Q

Causes of fetal bradycardia

A
  1. Acute hypoxia
    ø Idiopathic and benign if short lived
  2. Drugs:
    ø Beta Blocker
    ø LA administration
93
Q

Most dangerous fetal rhythm

A

FHR < 60 bpm

will result in cardiac decompensation

94
Q

what are some things nurses may do as first line if baby is experiencing bradycardia?

A
  • supplemental O2
  • change mom position (all fours)
95
Q

If baby’s heart rate does not return to normal (after bradycardia) after a couple minutes, what will the next course of action?

A

STAT C-section

96
Q

Temporary increase in FHR

A

Acceleration

97
Q

requirements to considered “acceleration”

A

<32 weeks: 10 bpm >15 sec, but <2 min

>32 weeks: 15 bpm >15 sec, but <2 min

98
Q

Causes of fetal accelerations

A

Fetal movement
Fetal stimulation
Maternal contractions

99
Q

Accelerations are said to correlate with ____.

A

fetal well-being

reassuring sign; if they occur often mother may get supplemental O2

100
Q

Gradual decrease and return to baseline

A

Deceleration

101
Q

the lowest point of decel (slowest FHR):

A

Nadir

102
Q

Early or late decels are termed in relation to ____.

A

uterine contraction

103
Q

EARLY decels are said to occur when the FHR decreases coincide with ____.

A

onset of uterine contractions

104
Q

Early Decels:

Time from onset to the lowest point of deceleration is ____.

A

≥30s

105
Q

Early decels:

____ occurs with the peak of contraction.

A

Nadir

106
Q

Common etiology of early decels:

A

Fetal head compression (2/2 uterine squeeze)
Mild hypoxia (well-tolerated)

107
Q

Early decels are caused by ____ produced when the head is compressed by uterine contraction.

A

vagal response

108
Q

Onset and depth of early decelerations mirror ____.

A

the shape of the contractions

109
Q

Early decelerations tend to be proportional to ____.

A

the strength of the contraction.

110
Q

Early decels graph picture

A
111
Q

T/F: Early decels are typically benign, common, and not an emergent situation.

A

True

112
Q

Graphically speaking, what is the difference in early and late decels?

A
  • Late decels do NOT initiate with the onset of contraction; rather, the onset is at or after peak contraction.
  • The Nadir occurs AFTER peak contraction (shifted right).
113
Q

Late decelerations are characterized by decreasing FHR waveform and a return to baseline. The onset to Nadir is ____ seconds.

A

> 30 sec

114
Q

Common etiology of late decelerations:

A

Uteroplacental insufficiency (prolonged asphyxia & fetal hypoxia)

Hypoxia causes bradycardia, not contraction like in early decels

115
Q

What type of decel?

A

Late decels

116
Q

An abrupt, visually apparent decrease in the FHR below the baseline & recovery

A

variable deceleration

117
Q

Variable decelerations have what onset to nadir?

A

<30 seconds

118
Q

Common etiology of variable decelerations:

A
  1. Cord Compression
    ø Due to oligohydramnios (↓ Amniotic Fluid)
  2. Sustained head compression (vagal response)
119
Q

Variable decelerations have a ____ relationship to contraction.

A

variable (duh)

120
Q

if decel has a Nadir that occurs after peak contraction, it is either a “LATE” decel or “VARIABLE” decel; how can we decide?

A

LATE: onset to Nair > 30sec

VARIABLE: onset to Nadir < 30 sec (“abrupt”

121
Q

What type of decel?

A

Variable decel

122
Q

What type of decel?

A

Variable Decel

123
Q

The more severe & sustained the bradycardia = the more severe the hypoxia = the higher the ____ of the baby

A

stress

124
Q

Besides sustained bradycardia, what are the two worst rhythms?

A
  • late decels
  • variable decels
125
Q

VEAL CHOP mnemonic picture

A

I&M II (7 decks)

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