intrapartum nursing assessment and fetal monitoring basics Flashcards
psychosocial factors associated with a positive birth experience
choosing a physician/certified mid-wife who has similar philosophy of care - its important to be on the same page in case of emergency
maternal assessments during labor
monitor vs, be alert to preeclampsia, infection, hemorrhage; perform vaginal exam and assess labor status; labs urine, CBC, type and screen
maternal assessments during labor: vaginal exam /labor status
- Cervical effacement, dilation, fetal station
- Rupture of membranes (ROM) time and color if ruptured (nitrazine test, ferning)
- UC pattern (palpate or use fetal monitor)
- Fetal heart rate pattern
assessments during labor contd.
cultural- birth plan
psychosocial - attended CB classes, support during labor, evaluate womans response to labor/pain
latent phase
active phase
transitional phase
fetal presentation and position
inspection, palpation (leopolds maneuvers and vaginal exam) ultrasound
leopods maneuver determines
fetal position, presentation and lie
fetal heart rate
heart best through fetal back, find back using leopolds maneuver, doppler, electronic fetal monitoring (EFM)
leopolds maneuver first maneuver
palpate fundus of uterus with both hands - which part occupies the fundus?
am i feeling buttocks or head?
leopolds maneuver second
palpate one side of the uterus, then the other - where is the fetal back? where are the small parts or extremities?
electronic fetal monitoring (EFM)
can be continuous or intermittent, external and internal monitoring
EFM external monitoring
- Ultrasound transducer measures FHTs (Fetal Heart Tones)
- Tocodynamometer “Toco” measures UC’s (Uterine Contractions)
EFM internal monitoring
- Must have ruptured membranes
- Internal electrode attached to baby’s scalp for FHTs- increased risk for infection (water has to be broken)
- Intrauterine pressure catheter (IUPC) measures internal pressure of UCs- for contractions (water has to be broken before it’s placed)
- Done when external monitoring not adequate
EFM advantages
noninvasive, membranes do no not have to be ruptured, performed by nurse
EFM disadvantages
contraction intensity not measured, movement required repositioning, quality affected by obesity and fetal position
indications for continuous EFM monitoring
Multiple gestations Oxytocin administration Placenta previa or abruptio placentae Maternal complications (hypertension, diabetes) IUGR – intrauterine growth restriction Meconium stained amniotic fluid Fetal distress Premature/postdate Abnormal NST/CST/BPP any bleeding c-section ?
fetal heart rate patterns measured by assessing the
baseline rate, variability, periodic changes
fetal HR patterns baseline rate
look at range of FHT over 10 min, normal is 110-160
fetal HR patterns variability
change in HR over sec/min
fetal HR patterns periodic changes
changes that occur over time/ with stress of activity
- accelerations= transient rises in FHTs
- decelerations= periodic decreases in FHTs
normal FHR
110-160 bpm
tachycardia
above 160 bpm for 10 min or more
bradycardia
below 110 bpm for 10 or more
fetal tachycardia most common causes
(baseline >160 bpm)
maternal fever, fetal infection, mild fetal hypoxia, neurologic immaturity/prematurity
Fetal Tachycardia Nursing Interventions
Assess maternal VS especially temp Assess duration since ROM - >24 hours increases risk of infections Intrauterine resuscitation: - Change maternal position (left side) - Increase IV rate - Oxygen therapy via mask at 8-10 l/min - Turn off Pitocin (oxytocin) if running *Notify M.D./CNM immediately*
fetal bradycardia most common causes
(baseline <110 bpm)
fetal hypoxia, postdates fetus, congenital fetal cardiac anomaly, may be maternal HR
Fetal Bradycardia nursing interventions
Check maternal pulse to rule out monitoring mother’s heart rate instead of FHR
Check fetal gestational age (post maturity)
Intrauterine resuscitation:
-Change maternal position (left side)
-Increase IV rate
-Oxygen therapy via mask at 8-10 l/min
-Turn off Pitocin (oxytocin) if running
Notify M.D./CNM immediately
Prepare for immediate delivery, especially if FHR < 80 BPM
FHR variability
Reflection of the “push-pull” effect between the sympathetic and parasympathetic nervous systems
Presence of FHR variability is an indicator of fetal well-being
different amounts of FHR variability
none= straight line -non-reassuring minimal= (< 5/min) -watch closely moderate= 6-25/min- reassuring
decrease in variability possible causes are
Anything that depresses the fetal CNS
- Fetal sleep
- Oxygen deficits/hypoxia
- Prematurity
- Cardiac or CNS anomalies
- Narcotics or tranquilizers (drugs/medications
Nursing Interventions for minimal or absent variability
Note time, type of meds given -Is baby “drugged”? Check EDB -is baby neurologically immature? What to do...Intrauterine resuscitation: -Change maternal position (left side) -Increase IV rate -Oxygen therapy via mask at 8-10 l/min -Turn off Pitocin (oxytocin) if running
Notify M.D./CNM immediately
FHR periodic changes
accelerations (caused by fetal movmt/NST)
decelerations (early, late, variable)
FHR Transient Changes Early Decelerations
Benign, seen in active labor
What do they look like?
-Typically uniform in shape (not irregular or spiky)
-Mirror the contraction (begin & end w/ UC)
-Rarely falls below 100-110 bpm
Probable cause is head compression
Interventions: NOTHING except monitor to ensure a more ominous pattern does not develop
FHR Transient Changes:LATE Decelerations
An ominous sign!
What do they look like?
- Begins at or after peak of the contraction
- Have smooth uniform shape
Probable Cause: Uteroplacental insufficiency (UPI)
- Decreased blood flow with contractions, impedes fetal oxygen transfer….fetal causes hypoxemia with UCs
early decelerations
Mirror each other - Peak of contraction mirrors the lowest point of FHR
late decelerations
No mirroring- FHR starts to drop at peak, lowest part of FHR lines up/matches when contractions are over
Interventions for Late Decelerations:
It’s all about intrauterine resuscitation!
Intrauterine resuscitation:
- Change maternal position (left side)
- Increase IV rate
- Oxygen therapy via mask at 8-10 l/min
- Turn off Pitocin (oxytocin) if running
- Notify MD/CNM anticipate need for C/S*
- *Keep patient and family informed**
FHR Transient Changes:Variable Decelerations
Variable Decelerations -Most variables are not serious What do they look like? -Unpredictable drops in FHR -Typically V, U or W ~ waveforms -Sudden drop in FHR, with quick return
Probable Cause: cord compression - cord is pushed up against the baby
Nursing Interventions for Variable Decelerations
Interventions:
- Change position to decrease cord compression
- May need O2, IV
- Watch for severe or prolonged variables with late component and decreased variability
- Rule out prolapsed cord– check cervix (if u feel it - stat c-section)
Emergency if prolapsed cord
- Give O2 mask, increase IV rate, Trendelenburg Position, push up presenting part, prepare for stat C/S!
category I
FHR 110-160, moderate variability
Accelerations present or absent
Early decelerations possible
Variable or late decels absent
category II
Tachycardia or bradycardia Minimal variability Absent variability without decels Marked variability Decelerations – late or variable with variability
category III
Absent variability with recurrent late or variable decels
Sinusoidal pattern- anemic, hypoxic (emergency)
VEAL CHOP
variable- cord compression
early - head compression
accelerations- okay
late- placenta insufficiency
