Test 2 EFM Video Flashcards
AFI (Amniotic fluid index)
Measure Fluid by Ultrasound
Normal changes with GA
Slowly increasing and decrease post term
Range norm…
5 - 25
Same as Fetal heart rate variability range for moderate
Abruption
Separation of Placenta from uterus wall
VEAL CHOPS
Variable Decelerations from Cord Compression = (Good or Bad) / What is the cause
Bad
Pressure changes noted from Baroreceptors
VEAL CHOPS
Early Decelerations from Head Compression = (Good or Bad)
This happens from….
Good
Vagal nerve response
VEAL CHOPS
Accelerations from O2 reserves (extra oxygen)
Good or bad
What does it mean….
Good
Baby is active
VEAL CHOPS
Late decelerations from utero-Placental Insufficiency (Good or bad)
How is it detected
Bad
Chemoreceptors from chemical changes
Prolonged decelerations =
Greater than 2 but less than 10 minutes
VEAL
CHOP
Stands for…
Variable Decelerations/ Cord Compression BAD
Early Decelerations/ Head Compression GOOD
Accelerations/ O² Reserves GOOD
Late Decelerations/ uetro-Placental Insufficiency BAD
FHR Strip
6 small boxes = 1 large box
What length of time is 1 large box?
1 min
10 sec = small box
Background information for FHR Strips
GA of baby
Accelerations change at GA
<32 weeks 10x10
> 32 weeks 15x15
Background information for FHR Strips
Is mom feeling baby moving
Moving baby correlates with moving baby
Background information for FHR Strips
Ruptured AROM/SROM or low fluid (oligohydramnios/ low AFI)
Will have this affect on variable Decelerations
Increase
Fluid acts as a cushion for the cord. When the fluid is low the effect is increasing variable Decelerations
Background information for FHR Strips
Maternal fever
This affect on FHR
Fetal tachycardia
Background information for FHR Strips
If fetal monitor is showing Contractions
Do this assessment to mom….
Ask if she feels the Contractions
Palpate the abdomen & simultaneously look at graph to see if they correlate
Background information for FHR Strips
What is a normal Resting Tone for the uterus….
Soft & non-tender Between contractions
Oxytocin/ misoprostol = this affect on contractions / Increased Risk of….
Nalbuphine (Nubain) & Butorphanol (Stadol) this affect on FHR
Magnesium Sulfate ( Used for treatment of Tocolysis for preterm labor, Preventing preterm birth, Preventing & treating eclampsia & preeclampsia
Epidural….
Narcotics
Oxytocin/ misoprostol = Longer, Stronger, Closer together
Increase risk of Tachysystole >5 in 10 minutes
Nalbuphine / Butorphanol (Analgesics) makes mom & baby feel “outta it” DECREASED VARIABILITY
Magnesium Sulfate can lower base fetal HR
Epidural decrease moms BP, resulting in less perfusion to baby (LATE DECELERATIONS)
Narcotics: Pseudosinusoidal FHR pattern:
Oscillation frequency: Synchronized with the frequency of uterine contractions
Amplitude: 19 beats per minute (bpm) or more
Frequency: 1.3 cycles per minute or less
What condiciones in the mother may have an impact on external FHR monitoring
Obesity
Common reason why you may have to adjust posistion on the External fetal monitor
Mother adjusted posistions
When applying TOCO monitor perform Leopold Maneuver first to assess placement
T or F
F
TOCO only needs to be at top of the Fundus
Use it to determine posistion of baby for Clearest US signal
Describe how to perform Leopold Maneuver….
Steps 1 - 3 Facing Mom / Step 4 Facing Away from mom
- Place both hands in fundus and determine if it’s the head or butt. Butt will feel softer.
- Slide hands down the uterus and determine which side is the back
- Pawlik’s Grip: using 1 hand determine if head is engaged in the pelvis
- Facing moms feet. Both hands lower abdomen to determine if babies neck is flexed or extended
For best placement of US you are looking for this landmark with the Leopold Maneuver
Fetal back
Which is preferred for delivery
Babies neck Flexed or Extended
Flexed. Chin towards chest
How to tell difference between TOCO & US monitoring equipment?
Which requires gel
Both look similar
TOCO will have a pressure monitoring disc on the back
US only requires gel
Wireless Monica has this use / advantage.
Fetal/ maternal ECG & Uterine electromyogram
Better on obese patients
ISL/ FECG/ FSE
Work how?
Nursing considerations…
Corkscrew into scalp of baby
Monitor for infection
Purpose of Blue port on IUPC (Interuterine Pressure Catheter)
Instill fluids
Fetal HR Strips
Steps 1. Baseline
Ignore Accelerations & Decelerations
Look for area in between contractions to determine baseline.
How to determine baseline using the above advice
Eyeball it. Between contractions
Normal variation
Amniotic fluid embolism
Cord Compression
Complete/ Congenital Heart block
Fetal arrhythmias
Maternal hypoglycemia
Hypothermia
Low BP Maternal
Drugs
Hypoxemia
Have this affect in fetal HR
Bradycardia
Fetal hydrops
Maternal Hyperthyroidism
Severe fetal anemia
Fetal heart failure
Arrhythmias
Fetal Hypoxemia
Drugs
Fetal sepsis
Chorioamnionitis
Maternal fever
Have this affect on Fetal HR
Tachycardia
How long of a strip to assess fetal baseline
2 min minimal
2 big boxes
How long of a change in FHR is needed to have a new baseline
10 minutes
Serious condition where abnormal amounts of fluid accumulate in two or more fetal compartments, such as under the skin (edema), in the abdomen (ascites), around the lungs (pleural effusion), or around the heart (pericardial effusion). This fluid buildup can lead to severe complications, including heart failure, organ damage, or even fetal death.
Fetal hydrops, or hydrops fetalis
Step 2 of FHR monitoring strips
VARIABILITY (How much the HR changes up / down)
Give ranges
Absent
Minimal
Moderate
Marked
Sinusoidal
Absent 0 BMP
Minimal 1 - 5 BPM
Moderate 6 - 25 Bpm
Marked >26
Sinusoidal: Smooth with a cycle of 3 - 5 smooth lines per minute and last >20 minutes
Smooth, sinewave-like undulating pattern in FRH baseline with a cycle frequency of 3 - 5 per minute and last >20 minutes = Sinusoidal
Describe reason why
Sinusoidal FHR pattern
Severe fetal anemia
Rh isoimmunization
Fetal hypoxia and can indicate fetal distress.
It requires immediate evaluation and intervention, as it’s considered a sign of fetal compromise.
Variability in FRH is due to…
Intact Nervous System
Fluctuations in Sympathetic (Increase) & Parasympathetic (Decreased)
Steps 2 Variability
To determine Variability Ignore Accelerations & Decelerations on the strip T or F?
Minium of 2 minutes of test strip
T
Etiology of (Marked or Decreased) variability
Hypoxemia/acidosis, fetal sleep cycle, drugs (Nalbuphine (Nubain) & Butorphanol (Stadol), Magnesium Sulfate, Narcotics), Premature delivery, arrhythmias, fetal tachycardia, preexisting neurological abnormalities, congenital abnormalities
Decreased variability
Etiology of (Marked or Decreased) variability
Fetal stimulation, drugs, mild/transient hypoxemia
Marked variability
Which type of variability is desired in FHR
Moderate 6 - 25 BPM
____ is the best predictor of fetal oxygenation
Variability
Moderate 5 - 25 is best predictor of fetal oxygenation
Accelerations differ according to GA
Describe
<32 weeks
>32 weeks
<32 weeks = 10 bpm × 10 seconds
> 32 weeks = 15 bpm × 15 seconds
FHR Step 3 is….
Accelerations
FRH baseline 125
What would be the peak for Accelerations
<32 wks
> 32 wks
And time frame
<32 wks ( 135 & 10 seconds)
> 32 wks ( 140 & 15 seconds)
Etiology of Accelerations (1)
Ways to illicit Accelerations…
Oxygen reserves: Happens due to fetal movement in response to stimulation and Increased FHR
Illicit: Fetal Scalp Stimulantion, sounds, vibration, drinking cold water, juice , eating, maternal movement
What is the longest time an Acceleration can last?
10 mins
After this it’s considered a new baseline
Steps 4 of interpretation of FHR strips
Decelerations
Abrupt decrease in FHR may or may not be associated with Contractions
Distinguish between Variable Decelerations & Early Decelerations
Cause?
Which are normal findings
How can you spot the difference
Shape?
Cause:
Variable Decelerations = Cord Compression BAD
Early Decelerations = Head Compression GOOD
FHR strip:
Onset:
Variabie Decelerations: Abrupt
Onset to Nadir <30 secs
Early Decelerations: Gradual
Onset to Nadir is >30 secs
Shape:
Variable Decelerations = V,U,W
Early Decelerations = Spoon shaped
Do Variable Decelerations happen with contractions?
Yes, but they can also happen from pressure being put on the Cord (Baby grasping cord, laying on cord)
Oligohydramnios Low AFI <5 will likely cause this condition…
Variable Decelerations
Cord compression due to low fluid level
Size of Variable Decelerations
Lower 15 FHR beats for atleast 15 seconds
Etiology
Cord compression detected by pressure sensing baroreceptors
Baby grasping cord, oligohydramnios, ROM, Prolapse/ Nuchal Cord
Variable Decelerations
Nursing interventions for Variable Decelerations ( Onset to Nadir <30 seconds)….
Nursing interventions for Early Decelerations (Gradual: Onset to Nadir: Equal to or >30 seconds)
Decrease pressure on the cord
Posistion changes
Evaluate how close to delivery with SVE PRN
Amnionfusion
Evaluate Oxytocin use
Early Decelerations; Continue to monitor, SVE to evaluate imminence of delivery, Consider cephalopelvic disproportion (Failure to descend)
IUPC The cap can be used for this purpose to help this problem…
Inject amniotic fluid
Helps with Variable Decelerations / Relive pressure on the cord
Decelerations
Increase or Decreased Oxytocin
Decrease
The Nadir of decelerations and peak of UC Mirror eachother in this Decelerations.
Is it a normal finding?
Early Decelerations from baby head being compressed
Yes normal finding
Variable Decelerations vs Early Decelerations
Describe the Onset time
Variable Decelerations (Onset to Nadir <30 secs)
Early Decelerations (Onset to Nadir > or equal to 30 sec)
Compare FHR of Late and early Decelerations what is the difference in appearance.
What is the same?
Both gradual (Onset to Nadir >30 secs) and spoon shaped.
Timing is the difference.
Nadir of late decelerations doesn’t match the peak of the UC. While Nadir of early Decelerations matches the peak of UC
Which FHR is the most serious
Late decelerations
Etiology
Utero-placental insufficiency = Perfusion problems. Detected by chemoteceptors
Uterine hyperactivity
Maternal hypotension
Maternal HTN
Abruption
Previa
IUGR
DM
Chorioamnionitis
Postterm gestation
Maternal anemia
SS anemia
Rh isoimmunization
Cardiac disease
Smoking
Nursing interventions
Late decelerations Dangerous
Nursing interventions: Increase perfusion and oxygenation through positioning.
IVF Bolus
02
Chemoteceptors that detect Ox and CO² are used to detect this problem
Late decelerations
Uterine hyperactivity, tachysystole, Doesn’t allow for perfusion between contractions.
Low maternal BP
Late decelerations
Difference between
Intermittent & Recurrent
Intermittent: Occurs <50% of contractions
Recurrent: Occurs >50% of contractions
UC frequency
Range in minutes
Measure….
Measured from beginning of contraction to the beginning of next contraction
To get range for contractions calculate which contractions…
Closest together and farthest apart
Always measure contractions with this time frame
Minutes
Never seconds
More than 5 contractions in a 10 minute period. Averaged over 30 minutes
Tachysystole
Step 6 is duration
Measure from beginning of one UC to the end of same
UC length: must be atleast ___ seconds to be considered an UC
Uterine “Irritability “…..
Duration is always measured in…
UC is atleast 40 seconds
Uterine Irritability is Uterine activy that last <40 seconds
Duration is always measured in seconds
UC duration is measured and seconds and given in this format
UC is minimal 40 sec
Range
50 - 110 sec
How to assess UC intensity with toco monitor
How to assess UC Intensity with IUPC
Palpation: Firmer the stronger the Intensity. Mild, Moderate, Strong
In addition, ask mother her subjective perception of UC Intensity
IUPC strips will be smoother lines. Read the mmHg in increment of 5
Step 8 resting tone of the uterus
Is the uterus resting between contractions.
Toco vs IUPC
Toco: Palpate the uterus (Soft & relaxed between contractions)
IUPC( Select average lowest number in between contractions) to determine Uterine Resting Tone
Step 9 Montevideo Units
Are the contractions strong enough for labor to progress?
Represents total intensity of each UC added together for 10 minute period
MVU >____ are considered adequate for 90% of labors to progress
200
How to calculate MVU ?
Which number indicates they are strong enough for labor to progress?
10 minute time span
Add all peaks of contractions and Minus from each peak the Resting Tone located to its right.
Add together all and if # is > than 200 it is 90% likely ready for labor
Step 10 FHR Category
Strong predictive of normal acid-base balance at time of observation.
Routine Care
Fetal heart rate tracing shows ALL of the following
Must have Baseline 110 - 160 BPM & Moderate Variability
May Have (Present or Absent) Accelerations & Early Decelerations
Can’t have: Late, variable or prolonged Decelerations
Which category
Category 1 NORMAL
Category 1 NORMAL
Must have Baseline ____ BPM & _____ Variability
May Have (Present or Absent) ______&_________
Can’t have: _____, ______ or ______
Which category
Fetal heart rate tracing shows ALL of the following
Must have Baseline 110 - 160 BPM & Moderate Variability
May Have (Present or Absent) Accelerations & Early Decelerations
Can’t have: Late, variable or prolonged Decelerations
Strong predictive of normal acid-base balance at time of observation.
Routine Care
Category ____ ABNORMAL
Predictive of abnormal fetal-acid base status at time of observation. Efforts to quickly resolve the underlying cause of abnormal fetal heart rate pattern should be made.
Fetal heart rate shows EITHER of the following
Sinusoidal pattern
Absent variability Plus One of the following
Recurrent late decelerations
Recurrent variable Decelerations
Bradycardia
Category III
Category III ABNORMAL
Predictive of abnormal fetal-acid base status at time of observation. Efforts to quickly resolve the underlying cause of abnormal fetal heart rate pattern should be made.
Fetal heart rate shows EITHER of the following
_______ pattern
______ variability Plus One of the following
________ late decelerations
________ variable Decelerations
Bradycardia
Fetal heart rate shows EITHER of the following
Sinusoidal pattern
Absent variability Plus One of the following
Recurrent late decelerations
Recurrent variable Decelerations
Bradycardia
A C/S is called in the FHR Category
Category II Intermediate
FHR Interventions
When seeing diffent types of decelerations
POISON IS AT CVS
P posistion change (Increases perfusion & Lowers Oxytocin Effects. Left/Right Lateral then hands and knees NEVER SUPINE)
O oxytocin off (Lowers fetal stess from contractions & Increases fetal Perfusion
I ivf Bolus: 300 - 500 mL (Increase Fluid volume, Perfusion to baby, Lowers Oxytocin effects)
S sve (Assess imminence of delivery, rapid vaginal change and cord Prolapse.
O o² 10 L face mask for material Ox Sat <95
N notify provider
I internal monitors Consider ISL/UPC placement for more accurate data
S support maternal coping (Fight or Flight = Catecholamine = Lower uterine perfusion
A aminoinfusion (Variable Decelerations ONLY Provides fluid cushion back around cord
T terbutaline Stops UC with unresolved tachysystole + fetal distress. Cardiac /PPH SE
C c/s or svd Deliver baby. Push, Forceps, Vaccumm. Remote from delivery = C/S
V vital signs
S staff help: Altert the team
Only decelerations caused by cord compression
Variable Decelerations
Terbutaline is used for this problem
Tachysystole (6 or more contractions in 10 min)
Terbutaline stops UC
SE = Cardiac/ PPH
26 y.o. G2P1 41.2 IOL for oligohydramnios (AFI 2cm)
26 years old
Pregant twice Give birth once
41 weeks 2 days GA
Induction of labor due to oligohydramnios (Amniotic fluid index 2) low AFI normal = 5 - 25
AROM (mec) and IUP/ISL placed at 1700.
Artificial rupture of membranes due to meconium in fluid. Internal monitors placed at 1700
Late decelerations = Utero-placental insufficiency which is a problem with…
Perfusion
When to use an Amnionfusion
Recurrent variable Decelerations
Describe
Category 1 Nomral FHR pattern (3)
Category 3 Abnormal
- (A) Must have Baseline 110 - 160 BPM & Moderate Variability
(B) May have (Present or Absent) Accelerations & Early Decelerations
(C) Can’t have Late, Variable, Prolonged Decelerations
Category III Either of the following
(A) Sinusoidal pattern
(B) Absent variability PLUS One of the following
Recurrent late decelerations
Recurrent variable Decelerations
Bradycardia
Mom gets epidural which type of Bad decelerations is expected…
Give interventions
Late Decelerations
Turn left side
Give O²
If HPTN give fluids
If oligohydramnios, call md, prepare for Amnionfusion
UPI uterine-placental insufficiency can happen from….
Interventions . ..
HTN/ Preeclampsia
Post Term
Turn left side
10L ox via face mask
Monitor BP
D/C IV oxytocin aka Pitocin
Call Dr
Which is bigger concern Variable or Late decelerations
Late Call Dr.
Variable you can monitor
Average fetal HR is rounded in increments of….
5 BPM
Onset to peak of Accelerations Time?
Duration of Accelerations?
Prolonged Accelerations
Onset to peak <30 ABRUPT
Duration 15 sec - 2 minutes
Prolonged 2 - 10 min
Variable Decelerations
V,U,W shaped
With or without contractions (Commonly occurs with UC)
Onset: Abrupt Onset to Nadir _____
BMP & TIME considerations to be considered Variable Decelerations….
Onset = Onset to Nadir < 30 secs
Variable Decelerations = 15 secs & 15 BMP lower
Early Decelerations / Late Decelerations
Shape: Spoon/ Saucer
Onset _____
Timing_____
Etiology ____
Onset Both Early Onset to Nadir + 30 sec
Time: Early: Decel mirrors UC ; Late Nadir of decelerations arrives after UC
Etiology: Early = Head Compression/ Vagal response
Late = Utero-placental insufficiency = Perfusion problems
Prolonged Decelerations are DANGEROUS.
Nursing interventions….
POISON IS AT CVS
