Unit 1- Electronic Fetal Monitoring Flashcards
What are the guidelines for intermittent auscultation?
REVIEW
- Assess for active labor
- Immediately after rupture of membranes
- Preceding and following ambulation
- Prior to and following pain medications and/or anesthesia
- Following-vaginal exam, enema, catheterization
- Events of abnormal or excessive uterine contractions
What are nursing considerations for intermittent auscultation & uterine palpation?
ASK
- Auscultate FHR for 30-60 seconds between contractions
- determine baseline: find out how baby is responding to moms contractions
- Auscultate, before, during and after a contraction
- determine FHR response to the contractions
- Identify any FHR patter
- Placement of electronic fetal monitor for assessment
FHM application and nursing interventions for FHM include?
REVIEW
- Provide education regarding continous EFM
- Patient comfort- empty bladder, position of comfort, left lateral to avoid vena cava compression
- Perform leopold’s- identify uterine activity- place toco on fundus
- Encourage frequent maternal position changes
- External FHM- ambulate for voiding
- Internal FHM- Bedpan
- Monitor vital signs- temp q 2hours after ruptured membranes
Leopold’s position helps identify uterine activity by….
ASK
Finding point of maximum impulse
True or false: With external FHM we can have mom walk as tolerated and place monitor back on for 20-30 mins increments.
True
After water breaks we should deliever the baby within…..
ASK
24 hours to reduce chance of infection
What are maternal indications for continous fetal monitoring?
ASK
- Gestation diabetes
- HTN
- Kidney disease
- Placenta abruption
- Placenta previa
- Induction/augmentation
- Cervical ripening or oxytocin
- Abnormal FHM testing
- Non stress or CST
What are fetal indication for continous fetal monitoring?
ASK
- Multiple gestations
- Post- date gestation
- IUGR
- Meconium-stained fluid
- Fetal bradycardia
What is internal fetal monitoring?
ASK
- Fetal scalp electrodes (FSE) attaches to presenting part
- Requires ruptured membranes with cervical dilation of 2-3 cm
- Intrauterine pressure catheter (IUPC)
- Measures uterine pressure in MMHG
- membranes must be ruptures
What are the benfefits of intermittent auscultation & palpation?
ASK
- Noninvasive
- Promotes “natural atomosphere
- Comfortable, and allows for ambulation
- Outcomes comparable- EFM in low-risk
What are limitations to intermittent auscultation & palpation?
ASK
- Difficult- if obese, unable to tolerate touch
- No permenant record of FHR or UA
- Unable to determine UA intensity
- Patterns not identified such as fetal hypoxemia
- Not recommended for high-risk
What are benefits of external fetal monitoring?
ASK
- Easy to apply
- Noninvasive- decreases the risk for infection
- ROM, Cervical dilation not required
- No known risk to women or fetus
- Permanent record of the FHR & UA
What are the limitations of external fetal monitoring?
ASK
- Maternal movement requires repositioning
- Contraction intensity is not measured
- Double FHR <60 BPM & Half FH> 180bpm
- Maternal HR may be recorded
- Maternal obesity, fetal size position or multiples
What are benefits to internal fetal monitoring?
ASK
- FHR tracing- not affected by movement, obesity or fetal position
- Displays FHR between 30-240bpm
- Identify fetal cardiac arrhythmias
- Accurate measurement- uterine activity
- allows for use of amnioinfusion
What are some limitations to internal fetal monitoring?
ASK
- ROM, cervical dilation required- increased risk of infection
- Risk of injury if imporperly placed
- Record maternal HR if fetal demise
- Excessive fetal hair can interfere
- IUPC reading vary based on IUPC types
- Inaccurate reading w/position changes
Each square on the x axis of an electronic fetal monitor is ____ seconds?
ASK
10
Each square on the y axis on a fetal heart monitor is ___ bpm?
ASK
10 BPM
What is another name for the beginning/peak of a contraction?
ASK
acme
What is duration during our uterine activity assessment?
ASK
Length of contraction from begining to end
What is does frequency mean in our uterine activity assessment?
ASK
The time between the beginning of one contraction to the beginning of the next
What is relaxation time mean during our uterine activity assessment?
ASK
End of the contraction to the beginning of the next
- > or equal to 60 seconds of relaxation to allow for uterine blood flow is ideal
What does resting tone mean?
ASK
Uterine tone at rest– obersved during our uterine activity assessment
Intensity of utierine activity refers to the…
ASK
strength of contraction at its peak
When should you palpate to determine intensity of contraction?
ASK
- During peak (acme) of contraction
How do we document intensity of uterine contraction?
ASK
- Mild or 1+ (easily dented)- nose
- Moderate or 2+ ( can slightly indent)- chin
- Strong or 3+ (cannot indent utures) - Forehead
How is IUPC measured?
ASK
Contraction strength measured in mmHg after membranes rupture
1. Mild contraction
2. Strong
What is considered normal uterine activity?
ASK
Normal- 5 or fewer contractions in 10 mins averaged over 30 mins
1. Last 45-90 seconds
2. Intenisty- 25-80 mmhg
3. Resting tone 10mm hg
What is considered abnormal uterine activity?
ASK
- Tachysystole- >5 contractions in 10 mins, averaged over 30 mins
- Hypertonic uterine activity-resting tone >20-25 mmhg
- Abnormal uterine activity- spontanous or stimulated labor
- Contributes- decreased uteroplacental blood flow: hyppoxemia, hypoxia, metabolic acidosis, metabolic academia
What is a baseline fetal heart rate?
ASK
110-160bpm
When using a FHM- must have at least 2 mins. of identifiable baseline segments that exclude accelerations, decelerations and marked variability
What is the most important indicator of fetal central nervous system health?
ASK
FHR
True or false: Moderate variablity means good CNS health?
ASK
True
What are periodic FHR patterns?
ASK
FHR changes in relation to the uterine contractions
1. Accelerations
2. Early decelerations
3. Variable decelerations
4. Prolonged decelerations
What are episodic FHR patterns?
ASK
FHR changes unrelated to uterine contractions
1. Accelerations
2. Variable decelerations
3. Prolonged decelerations
What are FHR accerelations?
ASK
Increase in FHR of in the baseline
1. Term- 15bpm above the 15 seconds
2. Preterm (<32wks.)- 10bpm above baseline for 10 seconds
For a NST how many accelerations in a 20 mins period must a baby have to have a reactive result?
ASK
2
For a NST how many accelerations must they have in a 40 mins period to be considered non-reactive?
ASK
No accelerations in 40 mins- follow up w/ CST
What causes a FHR acceleration?
ASK
Caused by sympathetic fetal response that can occur with fetal movement, contractions, vaginal exams or breech presentations. They are reassuring signs and indicates a healthy fetus.
What are our nursing interventions for FHR accelerations?
ASK
No nursing interventions required
What are early declerations?
ASK
FHR slowly decelerates as the contraction begins and returns to baseline as the contraction ends
Uniform in shape and mirrors the uterine contraction
What causes a early deceleration?
ASK
Benign parasympathetic response to fetal head compression
not associated with fetal compromise
What are our nursing interventions for a early deceleration?
ASK
No nursing intervention required- consider a vaginal exam to monitor labor progress
Typically about 5-6cm dilated at this point… usually a sign from baby that they are on their way
What is NDAIR as far as contractions go?
ASK
Lowerst point of the contraction
What is baseline variability?
ASK
- Baseline characteristic
- Normal irregulatrity of cardia rhythem
- Fluctuations (rise & fall) in baseline
- Excludes accelerations & decelerations
Baseline variablity is a predictor of…
ASK
Fetal oxygenation & reserve
What are the four categories of baseline variablity?
ASJ
- Absent- 0-1bpm- considreded non-reassuring
- minimal- <5bpm- consider possible fetal sleep cycle
- Moderate - Considred reassuring- 6-25bpm
- Marked- dependant on diff. factors- >25bpm
Absent or minimal- variabilty is a ____ sign
ASK
Non-reassuring warning sign
What causes absent or minimal variability? (fetal & Maternal)
ASK
Fetal
1. Fetal sleep cycle– normally last less than 30 mins
- ** #1 cause of decreased variability**
2. Hypoxia, hypoxemia, acidosis
- persistent decreased variability >60 mins despite intervention
- Prematurity, fetal anemia, preexisting neurological injuries
Maternal
1. Medications- narcotics, CNS depressents, Magnisium sulfate
2. General anesthesia
What is considered bradycardia for FHR?
ASK
<110bpm for 10 mins
> 90 bpm with variability is…
ask
benign-if tolerated by fetus
<80 bpm is a….
ask
obsterical emergency
What maternal/fetal reasons can cause bradycardia?
ASK
- Maternal hypotention (supine position is a NO)
- Medication induced- narcotics, mag. sulfate, anesthesia
- Late manifestation of fetal hypoxia- prolonged cord compression
- Fetal heart block
True or false: Post-term babies may have a slightly lower HR than a term baby?
ASK
True
Tachycardia is considred what on a FHR?
ASK
- > 160 bpm for 10 mins
- Persist 200-220 bpm- fetal demise may occur
What are fetal/maternal causes of tachycardia on a FHR?
ASK
Fetal
1. Early sign of fetal hypoxia
2. Fetal anemia
Maternal
1. Dehydration
2. Maternal fever, infection-chorioamnionitis
3. Maternal hyperthyroid disease
4. Medication-induced (atropine, terbutaline, hydroxine, illicit drugs, cocaine, meth)
What are the five factors (maternal and fetal) for adequate fetal oxygenation?
ASJ
Maternal
1. Normal maternal o2 saturation
2. Adequate exchange of o2 and co2
3. Sufficient blood flow to the placenta
Fetal
1. Placental circulation to the fetus throught the umbilical cord
2. Normal fetal ciculatory & oxygen- carrying functions
What is the fetuses response to stress?
ASK
- Prolonged hypoxemia depletes reserve
- Decompensation
- Aerobic to anaerobic metabolism
- Accumulation of lactic acid
- Metabolic acidemia
- Leads to cellular death
What is the fetal response to interruption in oxygen pathways?
FHR accelerations
Variable decelerations
Late declerations
What are 3 questions you should ask in terms of fetal response to interruption in oxygen pathway?
REview
- What do we call the pattern
- What does it mean
- What do we do about it
What are our nursing interventions to fetal responses to interruption in oxygen pathway?
ASK
Nursing intervention is based on cause
1. Assess fetal response to scalp stimulation
2. Consider internal fetal monitoring
3. Place patient in left lateral position
4. Consider intrauterine resuscitation (IUR)
What are variable decelerations?
ASK
Abrupt decrease in FHR- varied in shape, duration, depth and timing in relation to the contraction
Most common FHR pattern
Non-reassuring (ominous) signs of variable decelerations include?
ASK
Severe variable decelerations- FHR below 70bpm lasting greater to or equal than 30-60 seconds
- slow return to baseline
- Decreasing or absent variablility
- Intrauterine resuscitation nursing intervention required
What causes variable decelerations?
ASK
- Umbilical cord compression
- Prolapsed cord
- Nuchal cord
- Short cord
- Sudden rapid descent of the fetus
What are late decelerations?
ASK
Gradual decrease in FHR baseline that begins after the contraction & return & returns after the contraction is over
Late decelerations depth ____ inidicate severity, rarely falls below 100bpm?
ASK
Does not
What are ominous and potientally disastours non-reassuring signs of late decelerations?
ASK
- Associated with decreased or absent variability and tachycardia
- Indicates uteroplacental insuffciency-postdates, preeclampsia, diabetes, cardiac disease, placental abruption
What nursing interventions are required for late decelerations?
ASK
- Intrauterine resuscitation nursing intervention required
CST is postive if late decelerations occur or do not occur?
ASK
Occur
CST is considred negative when there are ____ late declerations?
ASK
No
What causes late decelerations?
ASK
- uteroplacental insufficency
- Maternal
- Hypotension
- placenta abruption
- preeclampsia/hypertensin
- diabetes
- placenta changes- abnormalities/post date
- uterine hyperstimulation or tachysystole
What is prolonged decelerations?
ASK
decrease in FHR below baseline lasting longer 2 mins or long but less than 10 mins
May be abrupt or gradual which can could be caused by interruption of uteroplacental perfusion or umbilical blood flow
Intrauterine resuscitation nursing intervention is required
What is intrauterine resuscitation (IUR)?
ASK
- Turn patient-maternal reposition-lest lateral 1st
- Stop oxytocin- reduce uterine activity
- Turn IV fluid up- Iv fluid bolus 500ml NS or RL
- Turn O2 on- apply oxygen 10L/min. non-rebreather mask
- Notify provider for immediate evaluation- you are responsible until notified
Additional considerations
1. Admin tocolytics (terbutaline)
2. Performing amnioinfusion-variable decelerations
3. Modifying second state pushing effors (every other contraction)
VEAL CHOP MINE…explain
ASK
- Variable-Cord Compression-Move the patient
- Early- Head compression- Intervention not nec.
- Acceleration- OK- NOthing
- Late- Placenta insufficiency- Emergency delivery
A category 1 FHR interpretation system means…
REVIEW/ASK
Category 1-normal
1. Predictive of normal fetal acid-base balance
2. FHR tracings Must have
- Moderate variability
- Baseline rate of 110-160bpm
3. FHR tracings may include the following
- Accelerations present or absent
- early decelerations present or absent
- Late or variable decelerations MUST be absent
4. No action is required- observe
A category III FHR interpretation system meams
ASk?review
Category III-abnormal
1. Predictive of abnormal fetal acid-base status
2. FHR tracings MUST have
- Absent variablity & any of the following
- Recurrent late decelerations
- Recurrent variable decelerations
- Bradycardia
- Sinusodial pattern
3.Initiate intrauterine resuscitation based on clinical situation
4.Category III patterns warrnet immediate provide evaluation & delivery
Category II FHR interpreatation system means?
ASK/REview
Category II- intermediate
1. fetal acid-base status is unknown
2. Tracings not categorized as cat 1 or 3
3. Requires continued intervention, evaluation and reevaluation
What are our nursing interventions for abnormal FHR patterns?
asl
- assess maternal vital signs
- confirm fetal heart rate vs. maternal heart rate
- Rule out maternal fever
- r/o maternal hypotension
- Assess maternal hydration status
- Assess abonormal uterine activity
- Assess for maternal anxiety and/or pain– can give small amount of pain medicaiton to relax
- Perform vaginal exam to r/o prolapsed cord
- Consider IUR
Accprdomg tp AWHONN FHR & uterine contraction assessments should be done when for high risk/low risk patients
ASK
- Latent phase of labor (0-3cm)- 30mins-60mins
- Active phase of labor (4-7cm)- 15-30mins
- Second stage of labor (10cm and/or pushing) 5-1mins
What is the minimum systematic assessment that should be done during labor?
Review
- Admission evaluation of the women and fetus
- Maternal-fetal assessments of FHR & UA using standarded defininations
- Baseline, variablity
- Presence or absence of accelerations, decelerations including type
- UA, frequency, duration, intensity and resting tone
- Corrective measures implemented and evaluations of responses
- Communication w/pt and support system
- Communication w/provider w/response and actions taken
What are the ABCD managment of FHR tracings?
ASK
A- assess the oxygen pathway-consider cause of FHR change
B- Begin conservative corrective measures
C- Clear obsticles to rapid delivery
D- delivery plan
Special monitoring cicumstancess for preterm include
ASK
- Physiological repsonse depends on fetal developmental stage
- Tolerance of stress may be different
- More likely to be subject to hypoxia
Characteristics include
1. Higher baseline w/in normal range
2. accelerations may have lower amplitude
3. variablity may be decreased
