326 Fetal Assessment - winter 2020 PDF

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winter 2020 ...

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Fetal Assessment During Labor Basis for Monitoring  Fetal response o Maintenance of oxygen supply to prevent fetal compromise  Biggest indication is by measuring FHT o Decrease in oxygen supply due to:  Reduction of blood flow through maternal vessels  Pt might be anemic  fetus not getting enough blood  Reduction in oxygen content in maternal blood  Alterations in fetal circulation  The cord around the neck, the cord having a knot  Reduction in blood flow to intervillous space in placenta  Placenta is detaching too early Monitoring Techniques  Intermittent auscultation (IA) o Listening to fetal heart sounds at periodic intervals to assess FHR o IA of the fetal heart can be performed with:  Leff scope  DeLee-Hillis fetoscope (PIC C)  Ultrasound device (doppler) o Easy to use, inexpensive, less invasive than EFM o Difficult to perform on women who are obese, or if they’re moving around a lot o Does not provide a permanent record – no strips, just professionals listening

Monitoring Techniques  Electronic fetal monitoring (EFM) o External monitoring  FHR: ultrasound transducer  UCs: tocotransducer o Internal monitoring  Spiral electrode  IUPC o Display  Monitor paper  Computer screen

External uterine and FHT monitoring

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Top – on fundus montitoring the contracitons Bottom – measuring the FHT

FHR Monitoring  External monitor o U/S device strapped onto maternal abdomen  Internal monitor o Scalp electrode placed on fetal head  Requires ROM – membrane has to be ruptured  If it is not rupture and they want internal monitoring they will rupture the membrane  Provider procedure – not nurses job  More accurate reading, especially if poor FHR tracing with external monitor Uterine Activity  Frequency: beginning of 1 cx to beginning of the next  Duration: beginning of cx to end of cx  Intensity of contractions: o External monitor ( TOCO )  Mild/ moderate/strong o Internal monitor ( IUPC )  Counted in montevideo units  Resting tone o May be hypotonic or hypertonic

Uterine Monitoring  Called Toco if external  Called IUPC if internal  External: place toco at upper 1/3 of uterus (fundal area) for best reading Internal FHR and UC monitoring  ROM must occur  Scalp electrod goes to the baby’s head  Catherter – gives reading of contractions

Leopold’s Manuevers – Auscultating Fetal Heart Rate  Leopold’s Maneuvers  4 steps to palpate uterus o These 4 steps are used to externally assess fetal position, and location of PMI for FHT o Page 443  View video & links under control panel in Bb shell. Contents in Folder # 2 Mosby’s Nsg Videos: Maternity Skills o Auscultating FHT

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LSA –Left sacral anterior o Listen to heart tone on a higher part of the belly

Internal Scalp Electrode  We want to see variability in the fetus heart beat  Look for the baseline

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Normal set of FHT and contractions are good

Fetal Heart Rate Patterns  Baseline fetal heart rate: average rate during a 10-minute segment not related to uterine cxn o Variability  Irregular fluctuations in FHR of two cycles per minute or greater o Tachycardia: baseline FHR greater than 160 beats/min o Bradycardia: baseline FHR less than 110 beats/min o RANGE – 110-160 bpm

Baseline Fetal Heart Rate  Rate o Normal 110 – 160 bpm o Bradycardia < 100 bpm o Tachycardia > 160 bpm  Variability: normal irregularity of fetal cardiac rhythm o Absent: undetectable** NONREASSURING o Minimal: undetectable to < 5bpm  **NONREASSURING if continues > 20 min  20 mins b/c baby have wake and sleep cycles o Moderate: 6 to 25 bpm – NORMAL o Marked: > 25 bpm may be indicative of stress if prolonged

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Baseline – 140 bpm Varability – minimal – nonreassuring The bottom tab is a non-stress test – we want the FHT to increase when mom feels the fetal movement o 15 beats and for 15 secs!! NO MORE OR LESS!!!

Absent – if mom is on narcotic

Fetal Baseline Tachycardia

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Baseline 170 bpm – tachycardia o Can cause by infection of the uterus  Minimal varability  2 contractions every 3 mins, durations of about 60 secs Fetal Baseline Bradycardia

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baseline 100 bpm – bradycardia o cardiac problems in fetus, hypotension in mom, infections absent variability no contractions

Fetal Heart Rate Patterns  Changes in FHR relating to uterine contractions  Periodic changes occur with Ucxn (VEAL CHOP)  Episodic (nonperiodic changes) not associated with Ucs (Baseline or variability changes)  Accelerations caused by dominance of sympathetic nervous response Interpreting Monitor Strips – PERIODIC FHR changes VEAL CHOP

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V ariable decelerations E arly decelerations A ccelerations L ate decelerations C ord compression H ead compression OK P lacental problems (uteroplacental insufficiency)

Variable Decelerations = Cord Compression  Caused by reduced blood flow through umbilical cord (cord compression)  Fall and rise in rate is abrupt  Shape, duration, and degree of fall below baseline rate are variable (not uniform in shape) o Change patients position  free up the cord

 Baseline around 150 bpm  Sudden drop – deceleration  Does not micmic the contractions!!! Variable Decel

Variable Decels  Required nursing intervention: o Change maternal position (get pressure off cord) o Increase fluid/ IV (increase blood flow to fetus) o Possibly think about amnioinfusion Early Decelerations = Head Compression  Head moving down to the pelvic  Mirror images of contraction  Return to baseline fetal heart rate by end of contraction  Maternal position changes usually have no effect on pattern  CONTINUE TO MONITOR, write early decal but doesn’t not need to intervene as long as HR is coming back after contraction  Associated with fetal head compression  Not associated with fetal compromise  Usually occur in active labor between 4-7 cms AND in the second stage of labor

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Baseline – 160 bpm Heart beat should return to normal once the contractions are over

Early Decel

nadir – lowest point Accelerations = O.K.  Temporary increase in FHR  15 bpm increase for 15 seconds = reassuring  Associated with fetal movement  Reassuring

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baseline – 130 bpm whenever pt feels FM the HR goes up and back to baseline

Late Decelerations = PLACENTAL PROBLEM!!       

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Begin after contraction begins (often near peak) Nadir occurs after peak of contraction May remain in normal range and not fall far from baseline Reflect possible impaired placental exchange Occasional late decelerations accompanied by moderate variability Utero-placental insufficiency Require nursing intervention to improve placental blood flow and fetal oxygen supply: o IV open (speed up)/ PITOCIN OFF/ position change (turn on left side)/ O2 via mask o Notify provider if recurring Document everything u do that minute on the strip!

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Baseline 150 bpm At the peak of the contration the FHT starts to decelerate

 really bad! 

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Baseline: Variability:

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Reassuring – Late decal – decal starts at the peak of the contraction Variable – does not micmic the contractions DON’T WANT FLAT LINE, WANT VARIABILITY!!!!

Care Management: Interpretation of FHT strips  EFM pattern recognition and interpretation  NICHD Workshop 2008 proposed a three-tier system for EFM interpretation o Category I: normal o Category II: indeterminate o Category III: abnormal  Fetal monitoring standards  Nursing management of non-reassuring patterns o IF U SEE SOMETHING ABNORMAL ACT ON IT!!!

Basis for Monitoring (not asked on exam)  Normal FHR patterns described as reassuring o Category I – everything looks normal  Baseline FHR in the normal range of 110-160 beats/min  Baseline fetal heart rate variability: moderate  Late or variable decelerations: absent  Early decelerations: may be present or absent  Accelerations either present or absent  Indeterminate FHR patterns o Category II – indeterminate, montor for a bit more to be determined  Bradycardia not accompanied by absent baseline variability  Tachycardia  Minimal or absent baseline variability not accompanied by recurrent decelerations  Marked baseline variability  No accelerations in response to fetal stimulation  Periodic or episodic decelerations  Abnormal FHR patterns described as nonreassuring o Category III – have to act on them  Nonreassuring FHR patterns associated with fetal hypoxemia  Hypoxemia can deteriorate to severe fetal hypoxia  Absent baseline variability  Recurrent or late decelerations  Bradycardia  Sinusoidal pattern – caused by fetal hypoxia

Non-reassuring Patterns    

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Tachycardia – don’t want Bradycardia – don’t want Sinusoidal pattern Absent or minimal variability, especially when associated WITH late or variable decels o Ominous sign!! SOMETHING IS GOIN ON WITHT EH FETUS!! o Think about  internal monitoring? Meconium? C-section? Late decelerations: repeated pattern Variable decelerations (ONLY if falling to less than 60 bpm for longer than 60 seconds) Prolonged decelerations: as stated above Hypertonic uterine activity (tachysystole) o Giving pt Pitocin but mom does not contract

Fetal distress: FHT changes  SINUSOIDAL PATTERN o Not variability o Caused by fetus hypoxia o Contractions are very close, don’t want that

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LOSS OF FHR VARIABILITY o Absent varibility

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SEVERE VARIABLE DECEL o No contractions, not assiociated with contractions o Very ominous signs something is wrong with fetus

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LATE DECEL o Deceleration start at the highest part of the contractions o Placental insufficiency

OMINOUS SIGN OF FETAL HYPOXIA  No contractions  Servere fetal hypoxia

Late Decels  notice the subtle decrease in FHT AFTER peak of cxn and flat baseline  minimal to absent variability  baseline 160 bpm  slight drop of HR at peak of contraction

Prolonged Deceleration  terminal bradycardia  baseline is 150-160  the contractions happen one after another

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write down everything you do on strip at the specific time AROM – they did a vag exam and decided to ROM to help with delivery of the baby A gush of fluids the cord prolapse against the cervix and the baby is not getting enough oxygen o Emergency delivery

Tachysystole: hypertonic uterine activity with associated bradycardia  Notice the frequency of uterine cxn with NO rest period.  NOTICE effect on FHT

Nursing actions to non-reassuring FHR patterns 1. Identify the cause o VEAL CHOP o Maternal VS (?ok)  If mom has hypotension – we would correct the hypotension on the mom o Maybe vaginal exam [prolapsed cord] 2. Stop pitocin if infusing 3. Reposition mom to reduce cord compression 4. Increase IV fluids 5. O2 8-10 L/min (increase maternal O2 saturation) 6. Consider internal monitors o ROM has to happen if internal monitoring 7. Notify primary provider o Might need emergency c-section 8. Be aware potential need for c/s Care Management  Other methods of assessment and interventions  FHR response to stimulation (fetal scalp stim)  Fetal oxygen pulse oximetry (via scalp electrode)  Amnioinfusion (cushion the cord with intrauterine fluid via infusion) o Increase maternal blood volume  Tocolytic therapy (relax the uterus activity)  Umbilical cord acid-base determination (cord pH)

REMEMB ER 

Key Points  Fetal well-being during labor is gauged by response of the FHR to UCs  Standardized definitions for common FHR patterns have been adopted by ACNM, ACOG, AWHONN  Five essential components include baseline FHR, variability, a  Accelerations, decelerations, and changes in FHR over time  Emotional, informational, and comfort needs must be addressed when the mother and fetus are being monitored  Documentation is initiated and updated according to institutional protocol  If we see an abnormal pattern, we have to do something and record it!!! NOTFIY PROVIDER!!!  Monitoring of fetal well-being o FHR assessment o Uterine activity assessment o Assessing maternal vital signs  Nurse must: o Assess FHR patterns o Implement independent nursing interventions o Report abnormal patterns to physician or nurse-midwife  RECORDING A LOT – IF U INCREASE PITOCIN THEN DOCUMENT IT ON STRIP!! CASE STUDY AND STRIP QUESTIONS ON EXAM...