Intrapartum Fetal Surveillance Flashcards by Kaylie Krauzyk

Intrapartum Surveillance

* Fetal surveillance identifies fetal well-being or compromise

* Use surveillance to assess & then intervene to prevent any complications in the fetus

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Fetal Oxygenation

* Using monitoring to identify issues of oxygenation during pregnancy & labor

Surveillance will not detect every compromised fetus

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What is required for fetal oxygenation?

* Normal maternal blood flow & volume to the placenta

* Normal oxygen saturation of maternal blood

* Adequate exchange of oxygen & carbon dioxide in the placenta (narrowing of spiral arteries can interrupt this)

* An open circulatory path between the placenta & fetus through vessels in the umbilical cord (into intervillous space & travels through umbilical cord to reach fetus)

* Normal fetal circulatory - oxygen-carrying functions

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Pathologic Influences on Fetal Oxygenation

* Maternal cardiopulmonary alterations

* Uterine activity

* Placental disruptions

* Interruptions in umbilical blood flow

* Fetal alterations

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Maternal cardiopulmonary alterations

* Hemorrhage

* Has an epidural (these cause vasodilation → feels hypotensive → dizzy)

* If has HTN (causes narrowing of spiral arteries)

* If has a maternal acid-base imbalance

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Uterine activity

Contractions that are too long (>90-120 sec), too frequent (closer than every 2 min) or do not give enough of a relaxation period (at least 60 sec)

If receiving synthetic oxytocin = longer

tachysystole

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With tachysystole is not allowing good utero-placental exchange to occur

* Can happen w/prostaglandin administration (we give these to ripen the cervix & prepare it for labor)

Tachysystole can occur spontaneously

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Placental disruptions

Abruptio placentae aka placental abruption

Placenta detaches from uterus prematurely

Bleeding out into abdomen from both sides (mom & baby)

Are areas of necrosis that can be in varying amounts on placental tissue

placental infarcts

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Interruptions in umbilical blood flow

* Cord compression

Nuchal cord - wrapped around the neck or between the pelvis & presenting part

Knot in the cord
Cord is short
Oligohydramnios
Baby grabs & squeezes own cord

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Fetal alterations

* Low fetal blood volume

* Fetal hypotension, anemia

* Cardiac issues like heart block

* A prolonged period of bradycardia or tachycardia can also impact fetal oxygenation

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Determining Proper Fetal Monitoring

___ is 1 of the best signs of measuring fetal oxygenation

Fetoscope / Doppler / EFM

Variability

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Fetoscope (less common nowadays)

Baseline Rate - Yes/No (?)

Variability - Yes/No (?)

Accelerations - Increases heard/absent (?)

Decelerations - Decreases heard/absent (?)

Rhythm - Yes/No (?)

Half Count/Double Count - Discerns/cannot discern differences (?)

Differentiate maternal & fetal heart rates - Yes/No (?)

* Yes

* No

* Increases heard

* Decreases heard

* Yes

* Discerns differences

* Yes [check mom’s pulse while listening to baby’s HR]

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Doppler (handheld)

Baseline Rate - Yes/No (?)

Variability - Yes/No (?)

Accelerations - Increases heard/absent (?)

Decelerations - Decreases heard/absent (?)

Rhythm - Yes/No (?)

Half Count/Double Count - Discerns/cannot discern differences (?)

Differentiate maternal & fetal heart rates - Yes/No (?)

* Yes

* No

* Increases heard

* Decreases heard

* Yes

* Possible half/double count

* May detect maternal heart rate [could be inaccurate; might pick up maternal HR & we think it’s baby’s]

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EFM

Baseline Rate - Yes/No (?)

Variability - Yes/No (?)

Accelerations - Increases heard/absent (?)

Decelerations - Decreases heard/absent (?)

Rhythm - Yes/No (?)

Half Count/Double Count - Discerns/cannot discern differences (?)

Differentiate maternal & fetal heart rates - Yes/No (?)

* Yes

* Identifies type of deceleration

* Possible half count/double count

* May detect & record maternal HR

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Fetoscope & handheld doppler used for ___ ?

* These provide mobility

We can’t view fetal tolerance of the labor

Can be disruptive, uncomfortable; needs a 1:1 ratio

intermittent auscultation

* Would not be able to do in a high-risk case; that needs continuous monitoring

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The best place for auscultation is ___ ?

Leopold’s maneuvers are helpful here to determine fetal placement

* Ask mother about exams & where she’s felt the baby kick

over the fetal back

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Auscultation Interpretation [using fetoscope & handheld doppler]

Category II (___)

Abnormal FHR baseline (tachycardia or bradycardia) OR

Irregular ___ OR

Presence of FHR decreases from ___

Nonreassuring

rhythm

baseline

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Auscultation Interpretation

Category I (___)

Normal range FHR baseline (?)

AND

Regular rhythm

AND

Absence of FHR decreases from baseline

AND

FHR increases may or may not be present

Reassuring

110-160

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Palpating Contractions

* Can time start to finish for duration

* Make observations for frequency

* Palpate uterus for intensity

> mild (tip of the nose)

> moderate (chin)

> strong (forehead, firm)

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Electronic Fetal Monitoring

110/120 - 150/160 = Normal

* Can be intermittent; in facilities → continuous monitoring

* May limit mobility

* Requires adjustment of devices as mom and/or baby moves

* Can be difficult to trace either baby or contractions in moms who have larger amount of abdominal fat

* Need an internal device to accurately assess intensity

Upper grid - fetal HR (beats/min)

Lower grid - uterine activity (mm Hg)

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EFM bedside unit

* Can monitor 2 babies

* Monitor mom’s contraction pattern, EKG, O₂ sat, & BP

* Can have an internal device for baby & get fetal EKG

Portable unit

* Good for high-risk patients

US transducer / tocodynamometer aka a “toco” device

* US transducer can pick up fetal HR

* Both are used & needed w/continuous EFM

* Devices need to be against the skin

* toco should be placed at the fundus

* Transducer placed below the umbilicus on the abdomen

Internal devices that connect to monitors (accurate but invasive) - Fetal scalp electrode

* Can give an accurate fetal HR

* Membranes need to be broken in order to apply this to the fetal head

! Risk of infection

* Displaces easily

* Can pick up maternal HR (from mother’s cervix)

Intrauterine pressure catheter (IUPC)

* Has a pressure-sensitive tip that picks up the actual amount of pressure in the uterus

* Will tell us what the intensity is but we can also palpate the fundus to ascertain the intensity

Evaluating Electronic Fetal Monitor Strips

The Display

Baseline \_\_\_ to ___ bpm is a normal FHR baseline For preterm is ___ to ___ bpm \* Look at when uterus is at rest versus contracting

110-160 140-160

The *Baseline* of the FHR is the average FHR over ___ minutes, rounded to the nearest 5 bpm \* Normal baseline 110-160

Bradycardia \< 110 bpm \* Needs to be \< 110 bpm & last for at least 10 min \* If \< 10 min, termed a **prolonged deceleration** (a prolonged drop in the FHR) \* To be an actual change in baseline to bradycardia, it needs to occur 10 min or more

Tachycardia Baseline \> 160 bpm \* Needs to be \> 160 bpm for at least 10 min If \< 10 min, termed a **prolonged acceleration** (a prolonged increase in HR but considered temporary) \* 10 min or more is considered a change in baseline & that is a true tachycardia

Can be due to infection, in response to dehydration or maternal rx's

Variability Moderate / Minimal / Marked **Variability as a key component to note the oxygenation status in the fetus** Are the fluctuations occurring in the **_baseline_** fetal HR? \_\_\_ variability is the best indicator of fetal well-being & adequate fetal oxygenation

Moderate (variability)

Moderate variability \_\_\_ to ___ bpm variation around baseline

6-25 bpm

Minimal variability \< ___ bpm variation around baseline

\< 5 bpm

Minimal variability \* In a fetus that is not as well oxygenated \* Fetal sleep \> Typical cycles ~40 min; if beyond 40 min, not r/t fetal sleep & more an oxygenation issue \* Narcotics, sedative rx's; alcohol or illicit drug use \* Magnesium sulfate given for preeclampsia \* Fetal tachycardia (d/t heart is getting tired & overworked)

\* Gestation \<28 wks b/c CNS isn't fully developed \* In fetal anomalies like anencephaly \* Cases of severe hypoxia or maternal acidemia or hypoxemia

Marked variability \> ___ bpm variation around baseline \* *With marked variability, you really can't distinguish what the baseline is* \* Is too much fluctuation from beat to beat to measure appropriately \* Do not like to see this

25 bpm

Fetal Accelerations & Decelerations - "VEAL CHOP" V = C E = H A = O L = P

**V**ariable deceleration = **C**ord compression **E**arly deceleration = **H**ead compression **A**cceleration = **O**kay (or oxygenation) **L**ate deceleration = **P**lacental insufficiency

Variable Deceleration Abrupt onset of nadir \< ___ sec with drop of 15 bpm below baseline for ≥ 15 sec but \< 2 min in duration \* Relationship to the contraction is variable \* Onset to nadir \< ___ sec

30 30

\* The umbilical vein is what's supplying oxygenated blood to the fetus \* The vein is the 1st to collapse

\* Is the only type of deceleration in which you see the fetal HR increase before & after

Early Deceleration Nadir of decel matches ___ of contraction Is onset to nadir \> or \< 30 sec ?

peak \> (greater than) 30 sec

\< 30 sec may be a variable If \> 30 sec may be an early or late deceleration \* Look at contractions \* **An early deceleration will mirror the contraction (_nadir will match peak of contraction_)** \* Early decelerations _are not_ associated with fetal compromise \* These could be really shallow or more pronounced

\* Head compression is normal in labor

Acceleration Acme of 15 bpm above baseline with duration \> 15 sec but \< 2 min \* Is an increase from the baseline of 15 bpm that lasts at least 15 sec but less than 2 min \* If we go over 2 min that changes it into a prolonged acceleration Accelerations reinforce good oxygenation; shown in response to fetal movement Prior to 32 weeks gestation expect a 10x10 rather than a 15x15 If less than 28 weeks gestation, no accelerations present d/t immaturity of ANS

\_\_\_ Deceleration Onset, nadir, & recovery of decel follow beginning, peak, & end of contraction Onset to nadir \> 30 sec **Nadir often occurs _after_ peaks of contraction** \* Concerning if they occur w/more than 50% of the contractions

Late \* Late decelerations are a sign of placental insufficiency = _bad_

Prolonged Deceleration Decel is ≥ 15 bpm and \> 2 min but \< 10 min

Sinusoidal Pattern \* Are associated w/high rates of fetal morbidity & mortality \* From severe anemia, narcotic use, severe fetal asphyxia or hypoxia, fetal infections, cardiac anomalies \* Sawtooth, waveform pattern \* Can see a pseudo-sinusoidal pattern - "false" d/t baby thumb-sucking \> Pattern will break

**\* Are a Category III fetal HR pattern; moving towards C-section**

Contractions: External Toco \* Frequency \* Duration \* Intensity \> mild, moderate, or strong? \* Resting tone (time between contractions; nothing happening; time where fetal oxygenation is happening)

Significance of Fetal Heart Rate Patterns Category I FHR Tracing Category II FHR Tracing Category III FHR Tracing

? Considered indeterminate Don't know if fetus is well oxygenated but not enough to support if needing immediate intervention

Category II FHR Tracing

? Absent baseline variability and recurrent late decelerations, recurrent variable decelerations, and/or bradycardia Sinusoidal patterns

Category III FHR Tracing

? Baseline within normal limits, moderate variability is noted, accelerations may or may not be present, early decelerations may be present, no variable, late, or prolonged decelerations noted

Category I FHR Tracing

Intrauterine Resuscitation: Interventions for Nonreassuring Patterns \* Identify the cause of the nonreassuring pattern to plan appropriate interventions (what decel is happening?) *Increase placental perfusion* \* Stop oxytocin or other uterine stimulants & administer tocolytics if ordered \* Reposition the woman (left lateral position) \* Increase the rate of nonadditive IV fluids

\* Administer oxygen via face mask at 8-10L/min (**to give more O₂ to the fetus**) \* Notify the provider as soon as possible \* Considering internal monitoring devices \* If severe, team members should be preparing for emergent delivery

Clarification of Data Fetal scalp stimulation Vibroacoustic stimulation Fetal scalp blood sampling Cord blood gases and pH

Fetal scalp stimulation \* If fetus has minimal or absent variability \* Rub against fetus' head to see an increase in HR Vibroacoustic stimulation \* Applying over maternal abdomen where it produces an auditory sound & tactile stimulation [vibration to abdomen]; apply for 3 sec & see if there's an inc in FHR \> Can repeat every minute for 3 times

Fetal scalp blood sampling \* No longer done in US but other countries \* Looks at pH; see if fetal acidemia present

Cord blood gases & pH \* Looks at pH (similar to fetal scalp blood sampling) \* O₂, CO₂, bicarbonate content \* To figure out if any acidemia present \* Can't be done until \> delivery

Always Assess Fetal Heart Rate... \* Upon admission \* Before AROM, after ROM ([artificial] rupture of membranes) \* If contractions become too frequent, last too long, inadequate rest between them (signs of tachysystole) \* Before administering oxytocin & throughout administration (before we stimulate the uterus)

\* Before administering cervical-ripening agents (e.g. prostaglandins) \* Before & after administering sedative medications or CNS depressants \* Before epidural analgesia & after placement (& during while infusing)