Management Of The FIRST STAGE Of LABOR (EFM)

Question 1

Part of Patient Preparation

Admit when _____
What to hook on the patient
What to do on PE
Place the patient on ____, ____, _____, ____

Answer 1

Admit the patient if she is having 1) contractions and 2) cervical dilatation of 3-4 cm - nasa active phase na

Hook the patient EFM - Labor Admission Test

PE: Do an IE with Clinical Pelvimetry to assess the 3 Ps (especially adequacy of passages)

Place the patient on the ff:
NPO (6-8 hrs in rel. to anesthesia), NSS, Analgesia, Lab Tests

Question 2

What PE will you do the 1st stage of labor?

Answer 2

IE + Pelvimetry + Assessment of the 3 Ps

Question 3

This monitors changes in the fetal heart rate pattern in relation to magnitude of the strength of uterine contractions

Answer 3

Electronic Fetal Monitoring (EFM)

Question 4

An adequate EFM strip is at least _____ minutes?
Should be checked after contractions every ______ minutes in the 1st stage of labor (cervical dilatation) and every _____ on the 2nd stage (fetal expulsion)

Answer 4

20 minutes

30 mins - 1st stage

15 mins - 2nd stage

Question 5

EFM: Parameters to identify
For FETAL COMPONENTS*
For MATERNAL COMPONENTS*

Answer 5

Fetal components (fetal heart rate) BVAD

1. Baseline FHR
2. Variability
3. Accelerations
4. Decelerations

Maternal components (uterine contractions)

1. Duration
2. Interval
3. Intensity

Question 6

How would you detect the BASELINA FHR sa tracing?

Answer 6

The approximate mean fetal heart rate which recurs in a 10-minute segment excluding decelerations, accelerations, contractions and periods of marked variability

Look at an area of the tracing which is LEAST VARIABLE

sustained for at least 2 minutes

Question 7

Normal value of BASELINE FETAL HEART RATE

For term and preterm

Answer 7

Term: 110-160 bpm
Preterm: 160 bpm

Question 8

Fetal bradycardia is _____ bpm for _____ minutes
What is management?

Fetal tachycardia is _____ bpm for _____ minutes
What is management?

Answer 8

Fetal tachycardia is >110 bpm for 10 minutes
DELIVER/TERMINATE PREGNANCY

Fetal tachycardia is >160 bpm for >10 minutes
INTRAUTERINE RESCUCITATION

Question 9

Most important parameter as it reflects CNS activity

Answer 9

Baseline Variability - fluctuations in the baseline FHR that are IRREGULAR in AMPLITUDE and FREQUENCY

Question 10

Define Minimal vs. Moderate vs. Marked Variability

Answer 10

Change in baseline FHR
Minimal - <5 bpm
Moderate - 6 to 25 bpm
Marked - > 25 bpm

Question 11

Wave-like undulating pattern with a cycle frequency of 3-5 bpm that continues for at least 20
Mins or more with loss of variability.

This would mean what?
What is the treatment?

Answer 11

SINUSOIDAL FHR PATTERN

Ominous sign of fetal anemia à do CS

Question 12

Define Accelerations:

Answer 12

AOG >32 weeks: Increase in FHR of at least 15 mins or more above the baseline for at leasdt 15 secs to 2 mins

AOG <32 weeks: Increase in FHR of at least 10 mins or more above the baseline for at least 10 secs to 2 mins

Question 13

What happens if Accelerations are already sustained for >10 mins?

Answer 13

Change in Baseline FHR

Question 14

Presence of acceleration in the intrapartum period is indicative of ___________

Answer 14

reactive and a healthy fetus

Question 15

Define “Decelerations”

Answer 15

Visually apparent, symmetrical & gradual decrease in baseline FHR of ≥15 bpm lasting for ≥15 seconds

Question 16

Begins with the onset of a contraction, nadir occurs
with the peak of the contraction, and recovery occurs
in conjunction with the end of the uterine contraction

Answer 16

EARLY DECELERATION

Looks like a “mirror image” of the graph of uterine
contractions below it

Question 17

What causes early decelerations?

Answer 17

HEAD COMPRESSION —> inc. ICP —> stimulation vagus nerve —> dec. Cardiac chronotropy —> dec. Blood flow to brain to dec. ICP

This is a normal finding especially if the fetus is descending from the pelvic canal

Question 18

This is a normal finding especially if the fetus is descending from the pelvic canal

Answer 18

Early deceleration :)

Question 19

Late deceleration is delayed (___ to ___ secs) in timing, with the nadir of the deceleration occuring AFTER the peak of contraction

Answer 19

Delayed 10 to 30 secs in timing
——V—— (FHR)
___/\_______(Contraction)

Question 20

What causes LATE DECELERATIONS?**
Explain this really well kasi it will save you a lot in the long run

What is the management?

Answer 20

UTEROPLACENTAL INSUFFICIENCY

Deprivation of fetal O2 —> fetus uses up its utero-
placental reserve of O2 —> vascular chemoreceptors send signals to the heart to decrease HR to CONSERVE O2 —> late decelerations because chemoreceptors need to reach a threshold first

Intrauterine rescucitation

Question 21

INTRAUTERINE RESCUCITATION

• how would you go about it?
• how many minutes?

Answer 21

1. Left lateral decubitus
2. Rapid IV infusion of 200-300 cc of non glucose crystalloid (NSS)
3. Maternal o2 supplementation at highest FiO2 (high flow O2)
4. Discontinue Oxytocin, give SC/IV Terbutaline 250 mcg to inihibit uterine contractions
5. IE to r/o Cord Prolapse - incase of prolapse, manually elevate the presenting part while preparing for delivery

Question 22

Rationale on why you would do Left Lateral Decubitus if (+) late decelerations

Answer 22

Relieve compression of IVC by the gravid + dextrorotated uterus
Positioning to increase blood flow
promote fetal oxygenation

Question 23

When you discontinue Oxytocin on Late Decelerations, what would replace it with?

Answer 23

SC/IV Terbutaline 250 mcg to inhibit uterine contractions

Question 24

This deceleration occurs before, during or after the contraction or even without contractions

What causes this?
Management?

Answer 24

Variable decelerations

-cause by CORD COMPRESSION (the baby is compressing the cord) and sudden variable cessations in umbilical blood flow.

Deliver if persistent despite resuscitative measures

Question 25

Define PROLONGED DECELERATIONS?

Answer 25

Visually apparent, symmetrical & gradual decrease in baseline FHR of ≥15 bpm lasting for 3 minutes but <10 minutes (if >10 minutes baby is dead)

Williams: decrease in Baseline FHR that is 15 bpm or more, < 2 minutes in duration. If the deceleration last 10 minutes or longer, it is a change in baseline

Question 26

If decrease in baseline FHR > 10 minutes what could this mean?

Answer 26

Baby is dead
Or
Change in baseline FHR (Williams)

Question 27

Management for Prolonged Decelerations?

Answer 27

Deliver if persistent despite resuscitative measures

Usually associated with rebound tachycardia and loss of variability, because the fetal heart is trying its last few efforts to increase HR

Question 28

What do we use to check for acid-base status of fetus?

Answer 28

Three-tiered FHR Interpretation System

Question 29

Enumerate under Category I EFM

FHR, Variability, Presence of accelerations, decelerations?

Answer 29

1. Baseline rate 110-160 bpm
2. Variability: Moderate (6 to 25 bpm)
3. Accelerations, pwede meron pwede wala
4. Early decelerations, pwede meron pwede wala
5. NO late or variable decelerations

Question 30

Enumerate under Category III

Answer 30

MINIMAL VARIABILITY + any of the ff:

1. Recurrent LATE decelerations or**
2. Recurrent VARIABLE decelerations or**
3. BRADYCARDIA**
4. SINUSOIDAL Pattern**

Question 31

If the EFM tracing is under Category II (Indeterminate), what would they require?

Answer 31

ACOG
These tracings typically require:
1. Closer Supervision
2. More frequent evaluation
3. Documentation and Correction of Abnormalities by Conservative Management and Intrauterine Resucitation